Outside The Box

“O utside the Box is arguably the best practical book ever written on ADHD.
Laden with compelling case examples that humanize this condition, the
writing is both authoritative and readable. Overall, the book masterfully blends
Outside the Box
Outside the Box: Rethinking ADD/ADHD in Children and Adults

the underlying science related to ADHD with extremely helpful guidance for
assessment and treatment. It is a ‘must read’ for anyone dealing with ADHD.”
Stephen P. Hinshaw, Ph.D., Professor, Depart-
ment of Psychology, University of California, Berkeley Rethinking ADD/ADHD
“T his book is another example of Dr. Brown’s exceptional ability to convey

complex information about ADHD to a broad audience in easily under-
standable terms yet based on the scientific evidence. It provides not only a fine
in CHILDREN and ADULTS
understanding of the disorder, its complexity, and its causes, but also a number
of insightful cases and evidence-based recommendations for its management.” A PR ACTIC AL GUIDE
A PR ACTICAL GUIDE
Russell A. Barkley, Ph.D., Clinical Professor of
Psychiatry, Medical University of South Carolina
“T his brilliant book by a superb clinician-researcher compresses a wealth of

vital, practical information into a marvelously user-friendly and engaging
format. It’s chock-full of everything anyone interested in ADHD wants to know,
arranged in such a way that you can find what you want and will never be bored.”
Edward Hallowell, M.D., author of Driven to
Distraction and other books
Outside the Box: Rethinking ADD/ADHD in Children and Adults—

A Practical Guide assails decades-old assumptions and
presents an up-to-date, science-based understanding of this disorder that
causes significant impairment and considerable suffering for 8%–10% of chil-
dren and at least 5% of adults.
Designed for the layperson, as well as for clinicians, the book offers sci-
ence-based answers—in plain, understandable language—to questions such as
“Why are those with ADD/ADHD able to focus very well on a few tasks in which
they have strong interest but are unable to focus adequately on many other
tasks they recognize as important?” “How is ADHD like having ‘erectile dysfunc-
tion’ of the mind?” “Is medication treatment for ADHD more or less risky than its
not being treated with medicine?”
Both down-to-earth and cutting-edge, Outside the Box: Rethinking ADD/
ADHD in Children and Adults—A Practical Guide highlights multiple perspec-
tives on how this disorder affects children and adults who suffer from it, as well
as those who love and care for them.
BROWN
Cover design: Tammy J. Cordova

Cover image: publicdomainvectors.org
Thomas E. Brown, Ph.D.
ADVANCE PRAISE FOR
Outside the Box
Rethinking ADD/ADHD
A PRACTICAL GUIDE
“This down-to-earth book shows what ADHD really is and what it isn’t.
Brown gives us a true ‘feel’ for ADHD and the impact of symptoms on peo
ple’s lives. He defines executive functions in clear examples just as his pa
tients described to him. For those who want an in-depth understanding of
ADHD as it occurs in children, youth and adults, this book is a must read.”
Michael J. Manos, Ph.D., Head of Pediatric Behavioral Health,
Cleveland Clinic
“Professor Brown translates complex science into everyday language.

This is THE guide for anyone having questions or doubts about ADHD.
Case descriptions are delivered in an empathic tone that only one who
has dedicated a lifetime to caring for patients and families with ADHD
could provide. Highly recommended for patients, their families, and
professionals interested in ADHD.”
Luis Augusto Rohde, M.D., Professor of Psychiatry, Federal University of
Rio Grande do Sul, Brazil, & President of the World Federation of ADHD
“This book is essential reading for anyone who wants to better under
stand ADHD across the life span. Brown gathers together some of the
best thinking and research from a variety of fields to answer some of the
most crucial questions about this still vexing and all-too-common con
dition. He has delivered a clear, comprehensive work that is both engag
ing and original. A rewarding, useful, and accessible read.”
F. Xavier Castellanos, M.D., The Child Study Center at NYU Langone
Medical Center, Department of Child and Adolescent Psychiatry
“Outside the Box offers an accessible update on the latest research about
ADHD and answers questions and doubts that many struggle with
about this disorder, which is very prevalent in children and adults all
over the world.”
Sandra Kooij, M.D., Ph.D., Chair, European Network Adult ADHD
“Tom Brown’s clearly written evidence-based update on attention-deficit/
hyperactivity disorder is a must read for professionals working with peo
ple struggling with ADHD as well as for adolescents and adults with
ADHD who are seeking a deeper understanding of the disorder. The many
clinical vignettes add interest and remind us of the person behind the diag
nosis. Sections debunking common misunderstandings and summarizing
important facts about ADHD are gems!”
Mina K. Dulcan, M.D., Head, Child and Adolescent Psychiatry, Ann and
Robert H. Lurie Children’s Hospital of Chicago and Professor of Psychiatry
and Behavioral Sciences and Pediatrics, Northwestern University Feinberg
School of Medicine
“Comprehensive, compassionate, and clear, Brown’s authoritative survey
on attention-deficit disorders integrates rich clinical experience with cut
ting-edge neuroscience and epidemiology. Brown’s own ‘out of the box’
views on such topics as measurement bias and nonpharmaceutical adjunc
tive treatment are compelling. This rigorous yet approachable text is ideal
for clinicians, academic researchers, parents, and patients alike.”
Ronald C. Kessler, Ph.D., McNeil Family Professor, Department of
Health Care Policy, Harvard Medical School
“Well written, clear, and concise, Dr. Brown’s Outside the Box explodes
many of the myths and misunderstandings surrounding ADHD. In his
calm, reassuring style, he provides the information families and young
adults with ADHD need not only to understand this disorder but also to
seek out proper treatment. This is a much-needed book amidst all the
confusion that abounds today.”
Patricia O. Quinn, M.D., Developmental Pediatrician, Washington, DC,
and author of 100 Questions and Answers About Attention-Deficit
Hyperactivity Disorder (ADHD) in Women and Girls
“Dr. Brown, a leading international expert in ADD and related conditions,
provides a superb, nuanced introduction to this multifaceted condition and
a rich, personal, compassionate exploration of the challenges faced by at
least 5% of the world’s population. His advice and guidance on how to an
ticipate and deal with the realities of ADD make this a must read for teach
ers, psychologists, and medical professionals, as well as for the parents,
teens, adults, and partners whose lives are directly touched, and potentially
derailed, by ADD. Dr. Brown’s guidance is especially important in today’s
world with its vast array of information, much of which is incomplete, con
tradictory, unscientific, outdated, and at times simply wrong.”
James F. Leckman, M.D., Ph.D., Neison Harris Professor of Child Psy
chiatry, Psychiatry, Pediatrics and Psychology, Yale University
Outside the Box
Rethinking ADD/ADHD
A PRACTICAL GUIDE
Outside the Box
Rethinking ADD/ADHD
A PRACTICAL GUIDE
by

Note: The authors have worked to ensure that all information in this book is ac
curate at the time of publication and consistent with general psychiatric and
medical standards, and that information concerning drug dosages, schedules,
and routes of administration is accurate at the time of publication and consis
tent with standards set by the U.S. Food and Drug Administration and the gen
eral medical community. As medical research and practice continue to advance,
however, therapeutic standards may change. Moreover, specific situations may
require a specific therapeutic response not included in this book. For these rea
sons and because human and mechanical errors sometimes occur, we recom
mend that readers follow the advice of physicians directly involved in their care
or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the
findings, conclusions, and views of the individual authors and do not necessar
ily represent the policies and opinions of American Psychiatric Association
Publishing or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/
specialdiscounts for more information.
Copyright © 2017 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
First Edition
Manufactured in the United States of America on acid-free paper
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Library of Congress Cataloging-in-Publication Data
Names: Brown, Thomas E., 1942- author. | American Psychiatric Association
Publishing, issuing body.
Title: Outside the box : rethinking ADD/ADHD in children and adults : a
practical guide / by Thomas E. Brown.
Description: First edition. | Arlington, VA : American Psychiatric Association
Publishing, [2017] | Includes bibliographical references and index.
Identifiers: LCCN 2017001965 (print) | LCCN 2017002321 (ebook) | ISBN
9781585624270 (pb. : alk. paper) | ISBN 9781615371341 (ebook)
Subjects: | MESH: Attention Deficit Disorder with Hyperactivity—pathology
Attention Deficit Disorder with Hyperactivity—complications | Attention
Deficit Disorder with Hyperactivity—drug therapy | Age Factors |
Comorbidity
Classification: LCC RC394.A85 (print) | LCC RC394.A85 (ebook) | NLM WS
350.8.A8 | DDC 616.85/89—dc23
LC record available at https://lccn.loc.gov/2017001965
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
The brain’s complexity is no accident—instead,
complexity it one of its central “design features” and
essential to its flexible and robust operation. Complexity, and
with it the capacity to respond and act differently under different
circumstances, is the brain’s answer to the persistent challenges
of a variable and only partly predictable environment.
Olaf Sporns
Networks of the Brain
The untangling of the complexity has barely begun....
But even at its early stages, the whole business of the matter of
the mind requires a global view if we are to get anywhere.
Gerald M. Edelman
Bright Air, Brilliant Fire: On the Matter of the Mind
As physicians strive to gather more data, to see more, to be more

objective, to be more scientific, they are often experienced by their
patients as not listening....Listening is central to learning about and
coming to understand a sufferer....The healer learns about the sufferer
in direct proportion to the quantity and quality of his listening.
Stanley W. Jackson
“The Listening Healer in the History of Psychological Healing”
Contents
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Chapter 1
Basic Facts and the Central Mystery of ADHD . . . . . . . 1
Why can persons with ADHD focus well on a few tasks or activities
but not on many others that they know are important?
Chapter 2
A New Model of ADHD
EXECUTIVE FUNCTION IMPAIRMENTS . . . . . . . . . . . . . . .11
What are executive functions, and how are they different in ADHD?
Chapter 3
Differences Among Persons With ADHD . . . . . . . . . . 27
How can really smart people, especially those who are not hyper
active, have ADHD?
Chapter 4
Ways ADHD Can Impair Functioning
at Various Age Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
How does ADHD change as you get older, and does it always start
in childhood?
Chapter 5
How ADHD Impacts “Brain Googling”
for Motivations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
How is the brain’s “googling” for motivations different for per

sons with ADHD?
Chapter 6
How ADHD Develops, Sometimes Gets Worse,
and Sometimes Improves . . . . . . . . . . . . . . . . . . . . . . . . 79
How and why does ADHD sometimes get better and sometimes
get worse as one gets older?
Chapter 7
How and Why Other Disorders Often
Co-occur With ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Why do individuals with ADHD tend to have additional learning or
psychiatric problems more often than most people without ADHD?
Chapter 8
Assessing Children, Teenagers, and Adults
for ADHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Why can’t ADHD be diagnosed accurately with objective tests?
What is an adequate way to diagnose ADHD, and who is quali
fied to do it?
Chapter 9
Emotional Dynamics in Individuals, Couples,
and Families Coping With ADHD . . . . . . . . . . . . . . . . 151
How and why are emotions so complicated in relationships be
tween persons with ADHD and their family, friends, partners, and
children?
Chapter 10
Practical Aspects of Medication Treatments
for ADHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
What medication treatments are safe and effective for adults, ad
olescents, and children with ADHD? What are possible risks or
side effects?
Chapter 11
Practical Aspects of Nonmedication Interventions
for ADHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
What are the uses and limitations of nonmedication treatments

for ADHD in children, adolescents, and adults?
Chapter 12
Treatment Adaptations for ADHD
With Various Complications . . . . . . . . . . . . . . . . . . . . . 233
How is ADHD treatment adjusted for persons who also have

other disorders and related medical problems?
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
About the
Author
THOMAS E. BROWN IS A CLINICAL PSYCHOLOGIST

who received his Ph.D. from Yale University and is Director of the
Brown Clinic for Attention and Related Disorders in Manhattan Beach,
California. He served on the clinical faculty of the Yale Medical School
for 20 years and is now Adjunct Clinical Associate Professor of Psy
chiatry and Behavioral Sciences at the Keck School of Medicine of the
University of Southern California. He is an elected Fellow of the Amer
ican Psychological Association and has lectured at universities and pro
fessional organizations throughout the United States and in more than
40 other countries. Dr. Brown is author of the Brown Executive Func
tion/Attention Rating Scales and four previous books: Attention Deficit
Disorder: The Unfocused Mind in Children and Adults (2005), ADHD Co
morbidities: Handbook for ADHD Complications in Children and Adults
(2009), A New Understanding of ADHD in Children and Adults: Executive
Function Impairments (2013), and Smart but Stuck: Emotions in Teens and
Adults with ADHD (2014). His Web site is www.DrThomasEBrown.com.
Dr. Brown has indicated a financial interest in or other affiliation with a com
mercial supporter, a manufacturer of a commercial product, a provider of a
commercial service, a nongovernmental organization, and/or a government
agency as follows: Publication royalties, American Psychiatric Press, The Psycho
logical Corporation, and Yale University Press; Consultant, research support,
speaker: Eli Lilly Co., and Shire, Inc.; Speaker: Jannsen Pharm; and Consultant:
Novartis and Shionoga Pharma.
xi
Preface
FIFTY YEARS AGO WHEN I BEGAN MY CLINICAL

training at Yale, the dominant approach to understanding psychologi
cal problems was psychoanalysis. That approach in our training had
significant limitations, but it had two great strengths: it emphasized the
subtle complexity of each individual and the critical importance of cli
nicians carefully listening to help persons discover the complexity of
their struggles and their own strengths. Over the past five decades, neu
roscience and technologies have brought impressive discoveries about
the amazing processes of brain development and functioning as well as
medication treatments that can significantly alleviate some sufferings of
the human mind.
This book is an effort to merge what I have learned from study of
psychological and neuroscientific research with what I have been
taught by a half century of trying to listen carefully while talking with
children, adolescents, and adults who have shared with me their per
sonal experiences with ADD/ADHD and related problems. I am deeply
grateful to my patients for all they have taught me about the subtle com
plexities of their attentional problems and their extraordinary strengths
in dealing with them.
The one who most helped me to refine my own ability to listen, to re
spect and to appreciate the complexities of others is also the one who first
encouraged me to write this book—my wife, Roberta (Bobbie) Brown, an
artist and writer, profoundly sensitive to beauty not only in art and po
etry but also in countless encounters of daily life. She was also a woman
of quick wit who greatly enjoyed dark, ironic humor. We shared 47 pre
cious years together as we raised our remarkable daughter and son, Liza
and Dave, both of whom, along with my sister, Nancy, and our grand
children, Noah and Simone, have continued to provide much love and
support to enrich my life, particularly since Bobbie’s death in 2014.
xiii
xiv OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
Throughout the process of writing this book, I have benefitted substan

tially from the steadfast assistance and down-to-earth advice of Dr. Ryan J.
Kennedy. For 4 years, he worked as my research assistant while complet
ing his doctoral training; he is now my associate on the staff of the Brown
Clinic for Attention and Related Disorders.
I owe thanks also to John McDuffie, Associate Publisher at American
Psychiatric Association Publishing, for nurturing this project over sev
eral years; to Maria Lindgren for skillfully and patiently editing my
countless revisions; to Greg Kuny, Managing Editor for keeping the
whole process moving; and to Tammy Cordova for designing the intrigu
ing cover for the book.

December 2016
Introduction
FOR DECADES, THE DISORDER CURRENTLY KNOWN

as attention-deficit disorder (ADD) or attention-deficit/hyperactivity
disorder (ADHD) has been stuck in a box of simplistic old assumptions
on the basis of having been identified long ago as a problem of little
boys who didn’t listen, were hyperactive, and chronically misbehaved.
Many of those assumptions were based on outdated understandings of
the human brain. Much remains to be learned about this syndrome, but
there is now enough scientific evidence to step outside that box to re
think old assumptions and to develop a more up-to-date, science-based
understanding of this disorder, which significantly impairs and causes
considerable suffering for about 8%–10% of children and at least 5% of
adults.
Below are 20 assumptions about ADHD that need rethinking in light
of recent research. Each is followed by a very brief statement of facts that
challenge that assumption and are reasons why it should be reconsid
ered.
Assumption #1: ADHD is a

simple problem of not listening
and not staying focused on a task.
Facts: Research has demonstrated that ADHD is impairment of a com
plex syndrome of brain functions essential for self-management: the ex
ecutive functions. These include motivation and prioritizing for tasks,
focusing and shifting focus as needed, managing sleep and alertness,
sustaining effort, modulating emotions, self-monitoring actions, regu
lating processing speed, and utilizing working memory to keep infor
mation in mind while attending to multiple tasks. ADHD-related
xv
xvi OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
impairments are more like the difficulties encountered when carrying

out the multiple functions involved in focusing on driving than they are
like the act of focusing a camera to take a picture. (See Chapter 2.)
Assumption #2: ADHD is essentially just

hyperactivity, impulsivity, and behavior
problems.
Facts: Many individuals identified as having ADHD have never had
any significant behavior problems and even those who had problems
with hyperactive behavior in childhood usually have much less diffi
culty with behavior problems from adolescence on. The primary prob
lems of ADHD are with attention, broadly conceived as the management
system of the brain, its executive functions. The DSM-5 (American Psy
chiatric Association 2013) label for this disorder includes the term hyper
activity even for individuals who are not and never were hyperactive.
This label perpetuates older views and widespread misunderstanding
of the disorder. (See Chapter 2.)
Assumption #3: ADHD affects mostly

males; girls and women rarely suffer
from ADHD.
Facts: During childhood and adolescence, three boys are identified with
ADHD for every one girl; however, the number of women diagnosed
with ADHD in adulthood is almost equal to the number of men with
that diagnosis. Reports from women seeking treatment for ADHD indi
cate that many of them have suffered for many years with undiagnosed
ADHD prior to their seeking treatment for themselves. (See Chapter 3.)
Assumption #4: Everyone has ADHD

sometimes.
Facts: All of the symptoms characteristic of ADHD are similar to prob
lems that everyone has sometimes, but not everyone has the severity of
impairment required for an ADHD diagnosis. For individuals diag
nosed with ADHD, those problems must be significantly more persis
tent and more impairing than for most persons of similar age and must
seriously interfere with many aspects of their daily life. (See Chapter 3.)
Introduction xvii
Assumption #5: ADHD always starts in

childhood, never in adolescence or
adulthood.
Facts: For decades, it has been assumed that ADHD always starts during
childhood, but recent longitudinal studies of individuals carefully eval
uated and found to not have ADHD during childhood showed that a sig
nificant percentage turned out to have developed ADHD impairments
by midlife. This may be due to their having ADHD impairments that
were not very noticeable until they met challenges for self-management
that arise only in adulthood, or it may be delayed action of genes, or
both. Usually, ADHD is inherited, but it is not always present in child
hood. Recent genetic studies indicate that, in some cases, genetic influ
ences impacting ADHD do not emerge and cause symptoms until
adolescence or early adulthood. (See Chapter 3.)
Assumption #6: ADHD is simply a lack of

“willpower”; they can do it when they
want to.
Facts: Virtually everyone diagnosed with ADHD has a few activities or
tasks for which they have no difficulty utilizing their executive func
tions, but these executive functions are significantly impaired for most
other tasks they do. This happens because strong interest in or strong
fear about a task changes their brain chemistry to overcome their usual
problems with motivation. However, this change is not under voluntary
control. (See Chapter 1.)
Assumption #7: ADHD is always

outgrown or always continues
for a lifetime.
Facts: Follow-up studies show that about 75% of individuals with
ADHD in childhood continue to experience significant ADHD-related
impairments into adulthood. However, about 25% no longer have sig
nificant impairment from ADHD during adulthood. For those whose
ADHD-related impairments do not persist, there are some measurable
differences in brain development relative to those who continue to ex
perience impairment from ADHD. (See Chapter 3.)
xviii OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
Assumption #8: There is no scientific

evidence for diagnosis of ADHD.
Facts: There is strong, objective, scientific evidence that ADHD is highly
heritable, that individuals with ADHD experience delays of 2–3 years or
more in development of specific areas of the brain that support execu
tive functions, that ADHD is associated with unique weaknesses of con
nection and communication between regions of the brain, that it is
associated with different patterns of cortical thinning, and that treat
ment with approved medications improves ADHD symptoms during
the times the medication is active in about 70%–80% of those affected.
(See Chapter 1.)
Assumption #9: Highly intelligent people

never have ADHD; they’re smart enough
to work around it.
Facts: Many studies have demonstrated that some children and adults
with high IQ have ADHD. Despite their intellectual strengths, they tend
to have significant weaknesses in working memory, processing speed,
motivation, and other aspects of ADHD that are independent of their
other cognitive abilities and often interfere with their ability to deploy
those strong abilities. (See Chapter 3.)
Assumption #10: ADHD is simply a

motivational problem; it has nothing
to do with emotions.
Facts: Research has revealed that emotions, mostly unconscious emo
tions, attached to the individual’s personal store of unconscious mem
ories and learning, are the primary basis on which each person’s brain
determines moment-by-moment motivation—what is, at that moment,
interesting and important, or not, to that individual. Working memory
problems of ADHD are associated with chronic problems in managing
these emotion-based motivations and priorities for activities of daily
life. (See Chapters 2 and 5.)
Introduction xix
Assumption #11: ADHD can be diagnosed

objectively with neuropsychological or
imaging tests.
Facts: Impairments of ADHD are demonstrated over time in many di
verse activities of daily life. They cannot be assessed adequately by brain
scans or neuropsychological tests done over a short time in an office. Ad
equate assessment requires an adequately trained specialist system
atically gathering information from self-report and others about the
person’s life situation, health, education, and many aspects of daily func
tioning over time and in various settings, relative to others of compara
ble age. A normed rating scale should also be utilized. (See Chapter 8.)
Assumption #12: Treating ADHD with

medications is more dangerous than not
treating ADHD.
Facts: Medications most often used to treat ADHD are controlled by the
government because if abused by taking excessive doses, they can be
come addictive. This causes some people to fear that even well-controlled
dosing could cause addiction. Research has shown that a child with
ADHD not treated with appropriate medication has double the risk of de
veloping a substance use disorder at some time in comparison with a
child who does not have ADHD. Those treated appropriately with med
ication for ADHD have no more risk of having a substance use disorder in
adolescence than would someone without ADHD. (See Chapter 10.)
Assumption #13: ADHD is unrelated to

other learning and psychiatric disorders.
Facts: Research has demonstrated that an adult with ADHD has six
times the risk of having at least one additional learning or psychiatric
problem that warrants diagnosis at some point in his or her life. This is
because the executive function impairments of ADHD often underlie
other disorders. Unfortunately, clinicians often diagnose and treat other
disorders with which they are more familiar, such as anxiety, depres
sion, dyslexia, mood disorders, or substance use disorders, but do not
recognize an underlying ADHD that may require treatment to help the
individual to attain adequate functioning. (See Chapter 7.)
xx OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
Assumption #14: Most medical and

mental health professionals are trained
to diagnose and treat ADHD effectively.
Facts: Most medical and mental health professionals, including psy
chologists, psychiatrists, and other physicians, have had very little or no
professional training in assessment or treatment of ADHD, especially in
adolescents and adults. Some have developed proficiency by getting ex
tra training for ADHD, but currently, this is the exception, not the rule.
(See Chapter 8.)
Assumption #15: ADHD looks pretty

much the same at every age level.
Facts: ADHD-related impairments are determined based on the level of
development of executive functions commonly demonstrated by most
individuals of similar age. Infrastructure of the brain that supports ex
ecutive functions develops very slowly and is not fully matured until
late teens or early 20s. A person with ADHD is one whose executive
functions are significantly underdeveloped or inconsistent relative to
those of most others of comparable age. (See Chapter 4.)
Assumption #16: Once adequate

executive function has developed,
it will persist.
Facts: Natural developments in midlife and beyond can impair execu
tive functioning. Also, as one gets older, normal development includes
some processes of decline. The aging process alone tends to produce
some impairments of executive functioning in persons not experiencing
disease processes such as dementia. For example, some women experi
ence in menopause some executive function impairments as their estro
gen levels diminish. Recent research has shown that treatment with
ADHD medications may help those women. Also, both genders tend to
experience some slowing of processing speed and diminution of work
ing memory efficiency as an aspect of normal aging. Some older adults
report that treatment with ADHD medication seems to alleviate these
developmental impairments somewhat. (See Chapter 6.)
Introduction xxi
Assumption #17: Current DSM-5

diagnostic criteria are sufficient
for recognizing ADHD.
Facts: Current DSM-5 diagnostic criteria for ADHD are based on re
search done with children 4–17 years old. Some additional examples of
symptoms in adults have been added, but many researchers agree that
although the current criteria pick up some impairments associated with
ADHD in adults, they do not include many aspects of executive function
impairments that are important aspects of the syndrome, particularly
some that may not be noticeable until late adolescence or adulthood.
(See p. xix.)
Assumption #18: ADHD is purely an

American problem; it is not found
elsewhere in the world.
Facts: When the same diagnostic criteria are utilized, ADHD is found in
most developed and developing countries, especially where there are
significant demands for literacy. Despite methodological differences
and regional differences, a meta-analysis of 102 studies including
171,000 individuals found the prevalence of ADHD to be 5.29% among
persons 18 years or younger from regions all over the world. (See p. xxii.)
Assumption #19: ADHD is really a

problem only during school years; it does
not have any significant lasting negative
impact on an individual’s adult life.
Facts: Long-term studies comparing sample groups of individuals with
ADHD to matched groups without ADHD show that those with ADHD
are less likely to complete high school, complete fewer years of post–high
school education, are less likely to complete a college degree, are more
likely to be employed in unskilled occupations, are more likely to have a
substance use disorder, and are more likely to quit or be fired from a job.
Some with ADHD are very successful in adult life, but for many, ADHD
related impairments bring many continuing difficulties. (See Chapter 3.)
xxii OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
Assumption #20: The importance of

ADHD is exaggerated by the media.
Facts: Media reports rarely describe the complexity of ADHD and the
multiple ways it impacts the lives of those millions of children and
adults and their families who experience this disorder, which is highly
prevalent in the United States and around the world. Population studies
have shown that, as a group, those with ADHD tend to have not only
many difficulties in education, employment, social interactions, and
other activities of daily life but also increased risk of premature death,
mostly due to accidents. One population study found that individuals
with ADHD also have elevated risk for attempted suicide and com
pleted suicide. (See Chapter 1.)
Goals of This Book

Outside the Box was not written solely to challenge mistaken assump
tions about ADHD. It is also intended to provide updated, science
based answers to questions many people have about attention-deficit
disorders. Some readers may wonder whether they may have ADHD
and how to get an adequate diagnosis. Others know they have ADHD
but have questions on whether it is safe to treat it with prescribed med
ications. Some are perplexed about why they or others they know are
able to focus and work very well for certain specific tasks or activities
but have serious ADHD problems when they try to focus on most other
tasks they need to do. Others believe they have ADHD but sensibly
wonder whether their chronic difficulties in school, work, or social re
lationships are actually being caused not by ADHD but by smoking too
much marijuana, excessive use of alcohol, or unrecognized psychiatric
problems. Still others struggle unsuccessfully in undergoing treatment
for their recognized anxiety, depression, learning disorder, or substance
use problems and reasonably question whether their unsuccessful treat
ment may be due to underlying ADHD problems that have never been
recognized or even asked about.
For most people at this time, it is not easy to get adequate answers to
questions like these. Media, the Internet, and countless books and mag
azine articles offer contradictory information, much of which is unsci
entific, outdated, and wrong. Many physicians, psychologists, and
other mental health professionals are not yet well informed about cur
rent scientific understanding of this complex disorder, which affects
millions of children, adolescents, and adults throughout the world and
Introduction xxiii
can seriously disrupt learning, employment, family relationships, social

interactions, health, safety, and self-esteem for decades or a lifetime.
This book offers science-based answers in plain, understandable lan
guage to a wide variety of questions about ADHD that are often raised
not only by adolescents and adults in the general public but also by pro
fessionals in pediatrics, general medicine, psychiatry, psychology, nurs
ing, education, and other related fields.
Unlike some books, this volume offers a science-based perspective
that is not limited to the understanding of ADHD provided in the cur
rent psychiatric diagnostic manual, DSM-5. DSM-5 is a valuable source
of information about ADHD, but its diagnostic criteria for adults are
based on field research with children ages 4–17 years and not on field re
search with adults. DSM-5 criteria do not include symptoms of execu
tive function impairment that are most highly predictive of ADHD in
adults and that most effectively distinguish ADHD from other psychi
atric disorders (Kessler et al. 2010). Rigid application of current DSM-5
criteria for ADHD does not adequately identify some adults signifi
cantly impaired by this syndrome.
The current name of this disorder is problematic. DSM-5 confusingly
continues to use the term attention-deficit/hyperactivity disorder to iden
tify persons with ADHD who do not have, and may never have had, any
problems with hyperactivity. Although the older term attention-deficit
disorder or the newer term executive function deficit disorder (EFDD)
would seem preferable, in this book I use the current official DSM-5
term attention-deficit/hyperactivity disorder to refer to presentations
of the disorder with or without hyperactivity or impulsivity. I also re
port and utilize scientific research findings that move beyond the con
straints of the DSM-5 description of ADHD.
The book’s table of contents lists the overall topic of each chapter
and also highlights one or two of the puzzling questions many people
have that are related to that topic. Each chapter includes broad informa
tion about its theme as well as answers to the specific topic question.
The chapters also provide much additional information on other related
questions about ADHD often raised by laypersons and professionals.
Embedded throughout each chapter are brief citations to sources for the
information provided; these sources can be consulted for additional,
more technical information. The reference list at the end of the book pro
vides more detail.
The subtitle A Practical Guide is intended to emphasize that this book
is focused primarily not on details of academic arguments but on prac
tical aspects of ADHD—how it varies from one person to another, how
it changes over the person’s life span, how treatments need to be ad
xxiv OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
justed to different individuals, and how it sometimes gets better and

sometimes gets worse.
The book is based on current scientific research and also on the ex
perience and perspective of a clinician who has invested most of his
work over more than 35 years in studying this disorder not only by
reading scientific studies and doing research but also through countless
hours of listening to, talking with, and providing treatment for a wide
variety of children, teenagers, and adults with ADHD and related prob
lems.
It is important to note that there is much ongoing research on
ADHD, some of which it is hoped will provide the basis for broader per
spectives and continuing improvements in our understanding of
ADHD and our ability to provide safe and effective treatment for those
who experience it. This book might be regarded simply as a statement
about the current picture of our developing understanding of these
complexities of the mind.
However, there is yet another purpose to Outside the Box. In this
book, I seek to highlight multiple perspectives on how ADHD affects
both individuals who suffer directly from it and those who love and care
for those children and adults who have ADHD.
Many people think of ADHD as a trivial problem of children or
adults who are scatterbrained, often a bit disorganized, frequently late,
and excessively forgetful. In contrast, some consider ADHD to be an ex
traordinary gift that endows the person with exceptional talent, creativ
ity, and the ability to “think outside the box.” Still others are convinced
that ADHD is simply annoying laziness or apparent lack of willpower
because they have seen that individuals with ADHD tend to focus and
perform quite well on a few tasks or activities in which they have strong
personal interest, even though they consistently fail to mobilize that
same level of focus and effort for many other activities that are impor
tant for others or themselves.
Yet for children and adults who are affected with ADHD-related im
pairments that warrant diagnosis, this disorder, when ignored or inade
quately treated, is not trivial. It is chronically frustrating, embarrassing,
and discouraging in multiple aspects of daily life. Although some people
with this disorder have impressive gifts of talents and skills related to
their ADHD and are quite successful, most of those individuals also are
seriously burdened by the disorder. Because of the persistent inconsis
tency it creates, this impairment of the brain’s self-management system
can destroy self-confidence and severely erode one’s hope for ever being
adequate to meet reasonable expectations of family, teachers, employers,
friends, or oneself.
Introduction xxv
One example is a 19-year-old young man who came with his parents
to consult with me over the Christmas break of his first year of college.
Let’s call him Jake.
Case Example: A college student who thinks

his life is hopeless
He was good-looking, friendly, and bright. He greeted me with a warm
handshake and a winning smile. As the four of us sat together in my of
fice, I asked Jake why he had come to see me. He said, “My parents want
me to talk to you because I went off to college last fall determined to be,
for once, a decent student. My parents and teachers always tell me that
I’m pretty smart. I did really well on my SATs, but since junior high, I’ve
never been a good student. I don’t get much of my reading or homework
done on time, sometimes not at all. Even when I know it’s important to
study more for a test or to get started early enough on a paper to do a
good job, I plan to do it, but then I keep putting it off until it’s way too
late. That’s why, despite my high SATs, I wasn’t able to get into any
school better than this pathetic little college I’m stuck in now.”
“I had figured I would go there, work hard freshman year, and then
transfer to a better college, the kind of school most of my friends are in.
I didn’t party much, but I also didn’t get much work done. Last week,
my first semester grades were posted. I got a B in one course where I had
a really interesting professor, but the other four courses were all Fs. My
plan to transfer to a better school, the kind of school I should be in, is
now down the toilet. My parents say they’re willing to pay for one more
semester to see if I can do better, but I don’t see how it’s ever going to get
any better. If I go back in 2 weeks for spring semester to try again, it will
probably be the same old thing I’ve been doing since junior high. I’ve
been thinking a lot this week about how my situation is totally hope
less.”
I spoke privately with Jake and asked him what he had in mind
when he told us that he saw his situation as totally hopeless. He fell si
lent for couple of minutes, and then his eyes filled up. “When I saw those
grades, it finally hit me that I really am going no place. I’ve been given so
much, and I’ve passed by so many opportunities! It’s too late now. Last
week while we were visiting at my grandparents’ house, I went into
their medicine cabinet and grabbed a bunch of pills. Then I got a bottle of
vodka. I took them to my room and hid them. Two nights ago, it was
about 2 A.M. and I was alone thinking about how hopeless my life is. I
took out the pills and laid them out in six rows. There were 180 of them.
Then I took out the vodka. I was going to start drinking the vodka and
then take every one of those pills. I wanted my life to be over because I
just can’t get myself to do what I need to do. I’m a loser!”
I asked Jake how he decided not to kill himself that night. He ex
plained that he had gotten into thinking about how deeply that would
hurt his parents for the rest of their lives. And he remembered that they
had made this appointment for him to see me to try to figure out a way
things might get better. He said he was not sure that anything would
xxvi OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
ever work for him, but he had decided to check out this consultation and
maybe give one more approach a try, even though he continued to have
serious doubts about whether it would actually work.
Not every person with ADHD feels so profoundly hopeless as Jake

did that evening, but many struggle often with persistent feelings of frus
tration, helplessness, and shame that result from their experiences with
inadequately understood and inadequately treated ADHD. Over the past
20 years, there has been increasing talk about ADHD among profession
als in medicine, mental health, and education, as well as in the media
throughout the world. Much of this talk has been argument about whether
this disorder is being overdiagnosed and whether increasing use of med
ications to treat ADHD in children and adults is a safe and useful benefit or
a risky mistake. Unfortunately, many of these polemical discussions have
not been adequately informed by relevant scientific facts or adequate un
derstanding of ADHD. More importantly, these discussions tend to com
pletely overlook or ignore the frustration and pain that those affected with
untreated or inadequately treated ADHD are forced to live with.
Scientific research about ADHD and the workings of the human brain
has generated substantial changes in our understanding of ADHD and
related disorders. In this book, I build on updated, science-based infor
mation to describe in very practical terms how ADHD can be recognized
at various ages, how it differs from more typical brain development, how
it can significantly impair those affected, and how it can be safely and, in
most cases, effectively treated in children and adults. Equally necessary
is an empathic understanding of the impact of ADHD on individuals and
family members who are affected.
I emphasize in this book the importance of empathic understanding
of ADHD and using this perspective to explain this syndrome to patients
and their families in understandable language. I also offer detailed, prac
tical strategies for providing empathic, science-based treatment for chil
dren and adults with ADHD and their families.
In 2014, psychologist Stephen Hinshaw and economist Richard
Scheffler published The ADHD Explosion, a book that describes various
scientific, economic, and cultural reasons for the escalating rate of youths
and adults being diagnosed with ADHD in the United States and inter
nationally. They estimated that, despite considerable stigma and social
controversy, lifetime rate of diagnosis for youths with ADHD may rise
over the next 5 years from the current estimated U.S. level of 11% to as
high as 13%. Their review concluded that
ADHD is here to stay and so is medication. ADHD is now an established

part of child, adolescent and adult mental health with more than suffi
Introduction xxvii
cient evidence for its largely biological underpinnings and major asso
ciated impairments.... Stimulants work far too well for individuals with
ADHD...for this diagnosis and such medications to quickly leave the
scene. (Hinshaw and Scheffler 2014, p. 161)
Some epidemiologists and other researchers have questioned the ac

curacy of estimates of ADHD prevalence such as those cited by Hin
shaw and Scheffler. Careful research suggests that reports of explosive
increases in the prevalence of ADHD in the United States and in other
countries throughout the world have been somewhat exaggerated be
cause they are based on counting cases without adequate attention to the
difference between those who have simply reported having symptoms
of ADHD and those whose symptoms have been carefully assessed clin
ically and found actually to meet levels of impairment required for legit
imate diagnosis (McKeown et al. 2015; Polanczyk et al. 2014). However,
even if prevalence of ADHD is not increasing “explosively,” there is rea
son to believe that the number of individuals who have ADHD is large,
and the number seeking treatment is likely to become larger as the dis
order is more adequately understood and as more adequate resources
for assessment and treatment become available.
Following their review of the rapid growth in the diagnosis of
ADHD, Hinshaw and Scheffler (2014) lamented that most of the individ
uals currently being diagnosed with ADHD receive seriously inadequate
assessments by clinicians who have had little training in assessment and
treatment of ADHD. They urged “that ADHD be diagnosed carefully by
professionals who know their business” and “that ADHD be treated by
clinicians (and paraprofessionals) who are versed in evidence-based in
terventions” (p. 166).
At present, most medical, mental health, and educational profes
sionals receive little or no instruction during their professional educa
tion to help them learn to recognize and treat ADHD in children or
adults. More adequate and updated education about ADHD is desper
ately needed for these professionals. Improved understanding of this
disorder is also needed in the general public so that parents of children
with ADHD and those adolescents and adults affected will have ready
access to updated, scientifically based information to counter wide
spread prejudices and misunderstandings.
This book is intended to provide understandable, science-based,
practical guidance for explaining and treating ADHD. It is intended for
the wide variety of clinicians involved in assessing or planning and
monitoring treatment of children and adults with this disorder: pedia
tricians; primary care physicians caring for children, adolescents, and
adults; psychologists; psychiatrists; neurologists; physician assistants;
xxviii OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
advanced practice nurses; and clinical social workers. It could also be

helpful to educators in primary, secondary, and postsecondary settings;
disability service providers; and human resource specialists, as well as to
adolescents and adults who are seeking more information about ADHD
assessment and treatment for themselves or for family or friends.
In this book, ADHD is understood not only in the limited terms of
DSM-5. It incorporates the DSM-5 ADHD diagnostic criteria as a useful
tool for clinical practice, but it also draws on a wider range of scientific
research and perspectives not yet incorporated into DSM-5. Prior to
publication of DSM-5, two of the researchers involved in revising the
section on ADHD offered a symposium at an annual meeting of the
American Psychiatric Association to describe to researchers and clini
cians the progress of their committee. After discussion involving many
questions from various researchers asking “Why are you not including
this or changing that?” the chairman made an important point. He said,
“You need to keep in mind that DSM does not lead the field; it follows
it.” This book includes some cutting-edge research and clinical strate
gies that gradually will be tested and improved on by subsequent re
search.
Since publication of DSM-5 in 2013, several respected researchers
have published criticisms and suggestions for how diagnostic criteria
for ADHD could be improved in the next version (Barkley 2015; Fayyad
and Kessler 2015). In the meantime, clinicians need to assess and treat
patients using not only the guidance of DSM-5 but also their clinical
judgment supported by the best they can glean from scientific research
and from more experienced clinicians. The authors of DSM-5 itself note,
“Diagnostic criteria are offered as guidelines for making diagnoses, and
their use should be informed by clinical judgment” (American Psychi
atric Association 2013, p. 21). This book is one resource to support that
clinical work while we continue to look for greater understanding and
more effective methods of treatment for children and adults with
ADHD.
1
Basic Facts
and the Central
Mystery of ADHD
CURRENTLY, THERE IS CONSIDERABLE CONTROVERSY

about attention-deficit/hyperactivity disorder (ADHD) in the media of
the United States and in a number of other countries. In print, television,
and online media, there are frequently alarmist warnings about the in
creasing numbers of children and adults being treated with medications
for ADHD.
Even the usually reliable and objective New York Times has published
sensationalized, negatively biased articles, such as the “Risky Rise of the
Good-Grade Pill” (Schwarz 2012) warning about increasing numbers of
high school students using or abusing ADHD medications as “academic
steroids” to help them gain an unfair advantage in their schoolwork or
on high-stakes tests such as the SAT. Although the article identified a
problem of abuse that legitimately warrants concern, it made no distinc
tion between the positive effects of stimulant medications properly used
for treating an impairing disorder and the misuse of such medications,
which can lead to addiction. Without such a distinction, warning quotes
such as “Once you break the seal on using pills [stimulants],...it’s not
scary anymore—especially when you’re getting A’s,” spoken by a teen
ager who abused stimulants and then became addicted to heroin, are
1
2 OUTSIDE THE BOX: RETHINKING ADD/ADHD IN CHILDREN AND ADULTS
likely to frighten away parents whose children legitimately need and

can benefit from medication for their ADHD.
Another sensationalized article appeared in the New York Times on
December 15, 2013 (Schwarz 2013), warning about “The Selling of At
tention Deficit Disorder.” That article quoted a psychologist who called
the rising rates of ADHD diagnosis “a national disaster of dangerous
proportions” and “a concoction to justify the giving out of medications
at unprecedented and unjustifiable levels.” The author of the article
suggested that advertising by pharmaceutical companies to parents has
been the primary cause for the rate of ADHD diagnosis for children
soaring to 15% from the earlier estimated rate of 5%. He implied that
any increase from the earlier estimated rate of ADHD is a dangerous
sign of excessive diagnosis.
Yet despite inadequately informed and negatively biased media
coverage, the rate of diagnosis for ADHD and use of medications for
this disorder has continued to increase not only in the United States but
also internationally (Polanczyk et al. 2014). Many reports on the magni
tude and rapidity of this increase appear to be exaggerated because they
are based on simply asking people about who has been diagnosed
rather than on medical records of careful evaluations (McKeown et al.
2015). Yet it is clear that increasing numbers of both male and female
children, teenagers, and adults have been diagnosed with ADHD and
have been receiving treatment for it over the past decade (Hinshaw and
Scheffler 2014; Visser et al. 2014).
So why is diagnosis of ADHD and treatment with ADHD medications
increasing so much in the twenty-first century? Is this increased rate of di
agnosis of ADHD and increased use of ADHD medication actually due to
careless diagnosis and aggressive promotion by pharmaceutical compa
nies? In their 2014 book about this expansion, Hinshaw and Scheffler
(2014) suggested multiple factors that may be fueling this increase:
• Escalating pressures for improved literacy and achievement from

students in school and postsecondary education, as well as for en
hanced work performance from adults whose jobs require more lit
eracy and complex technical skills
• Increasing recognition that ADHD affects not just males but also
many girls and women
• Accumulating evidence that ADHD impairments persist into adult
hood for many, although not all, of the individuals who are affected
in childhood
• Expanded access of some ethnic and racial minorities to resources for
assessment and treatment for ADHD
Basic Facts and the Central Mystery of ADHD 3
• Increased awareness that some very young (e.g., preschool) children

experience ADHD-related impairments and that early treatment can
improve their ability to benefit from schooling
All of these factors are influential, yet the most fundamental reason
for the escalating diagnoses and medication treatment of ADHD boils
down to two simple and related facts:
1. ADHD can cause considerable impairment and significant suffering

for affected individuals and families.
2. Medication treatments do not cure ADHD, but if appropriately ad
ministered, medication often can safely reduce impairment and im
prove functioning.
Persons with ADHD, even those who are very bright, tend to expe
rience a wide variety of impairments in their ability to learn and to man
age themselves in multiple activities of daily life: in their schooling,
family interactions, and social relationships. For some, these impair
ments are extremely costly to them and their families, at least during
childhood and/or adolescence and often also into adult years as they
encounter challenges of employment, driving a motor vehicle, manag
ing a household and finances, establishing and maintaining close rela
tionships, and, for some, parenting. Medications for ADHD, adequately
administered, do not cure, but often, although not always, they help to
alleviate these impairments and can improve quality of life. Increasing
numbers of persons in the United States and elsewhere around the
world are discovering that untreated ADHD is damaging and that, for
many, medication treatment for ADHD often works.
To fully appreciate why increasing numbers of individuals now
want to seek treatment for ADHD, it is helpful to have an updated un
derstanding of how scientific research has dramatically changed our
understanding of this disorder. Research studies over the past 30 years
have demonstrated that the disorder now known as ADHD is not essen
tially a disorder of misbehavior as it was understood in 1902. It is a com
plicated problem with the unfolding development and functioning of
the brain’s management system, its executive functions. It was not until
1980 that the term attention deficit was introduced into the name of the
disorder now known as ADHD. And it was not until 1980 that psychi
atric diagnostic criteria for ADHD began to include the possibility that
for some children with these attentional difficulties, symptoms may
persist into adulthood. Since that time, understanding of this complex
disorder has rapidly expanded.
Scientific research has taught us much more about the nature, causes,
course, and treatment of ADHD. Here is a summary of 12 important ba
sic findings that are explained further in later chapters.
1. ADHD is now understood as the impairment of the brain’s self

management system, which includes problems with getting mo
tivated, organized, and started on necessary tasks; focusing on what
needs to be attended to and shifting focus when needed; managing
alertness and sleep; sustaining effort to complete tasks; processing
and outputting information efficiently; managing emotions; using
short-term working memory; and monitoring one’s actions to fit the
setting and avoid excessive impulsivity. (See Chapter 2.)
2. All the characteristics of ADHD are problems everyone has some
times; however, individuals with ADHD simply have much more
chronic and impairing difficulty with these problems. ADHD is
not an all-or-nothing like pregnancy, where one either is or is not
pregnant. It is more like depression. Everyone feels down some
times, but a person who is simply unhappy for a couple of days
does not warrant a diagnosis of clinical depression. ADHD comes
in small, medium, and large levels of severity, but the diagnosis is
reserved for those significantly and persistently impaired by their
symptoms. (See Chapter 3.)
3. Although it is true that some children and adults with ADHD have
significant problems with hyperactive and excessively impulsive
behavior, many with ADHD have never had any significant be
havior problems and have never been hyperactive. The majority of
those who were “hyper” as children outgrow most of their hyper
active problems while continuing to have chronic difficulty with
inattention and related problems. (See Chapter 3.)
4. ADHD is highly heritable; it runs in families. Twenty-five percent of
children with ADHD have a parent with ADHD, and 30% have a
brother or sister with ADHD. Twenty studies comparing identical
twins, who share 100% of their genetic heritage, with fraternal twins,
who share just 50% of their genetic heritage, yielded a heritability in
dex of 0.75, indicating that most of the variability in developing
ADHD is accounted for not by family environment but by inherited
vulnerabilities (Faraone et al. 2005). Subsequent studies have dem
onstrated that this vulnerability is not due to any single gene; it is
due to a large number of genes in combination. (See Chapter 6.)
5. Longitudinal and other imaging research has demonstrated signif
icant differences in brain development and brain connectivity of
children and adults with ADHD compared with typically devel
oping individuals of similar age. Although much of brain devel

opment is similar, some specific areas of the brain that are
important for self-management tend to mature about 3–5 years
later in those with ADHD, and for some individuals, these prob
lems persist for much of their life. (See Chapter 6.)
6. It was once thought that a child with ADHD would certainly outgrow
the disorder sometime before reaching the age of about 14 years.
However, longitudinal studies have shown that about 70% of those
who have ADHD in childhood will continue to have some ADHD
related impairments at least into late adolescence. For many, but not
all, impairments of ADHD continue throughout the life span. (See
Chapter 3.)
7. ADHD is sometimes apparent during preschool years, but there
are many whose ADHD-related impairments are not noticeable
until they enter school or when they get into middle school, where
they no longer have just one teacher to provide structure and con
trol for most of each school day. Some do not demonstrate signifi
cant ADHD-related impairments until they enter high school or
when they move away from home and must deal with the chal
lenges of more independent life in college, university, or the early
years of employment. Several studies have also shown that those
with later onset of ADHD can be fully as impaired as those with
earlier onset. (See Chapter 3.)
8. ADHD has nothing to do with how intelligent a person is. Some
extremely bright and accomplished people suffer from ADHD de
spite high IQ. Studies have shown that ADHD is found in persons
across the full range of intellectual abilities. (See Chapter 3.)
9. Emotions play two important roles in ADHD, neither of which is
reflected in current diagnostic criteria. Conscious and unconscious
emotions play a critical role in problems of motivation and self
regulation that are pervasive in ADHD. Also, many individuals
with ADHD have chronic difficulty in recognizing and managing
expression of their emotions. (See Chapters 2 and 5.)
10. ADHD is not just one or two specific symptoms. It is a complex
syndrome, a cluster of impairments that often appear together, al
though some aspects of the disorder may be more or less promi
nent in any particular person. There are many differences among
various individuals with ADHD, even those of similar age. Per
sons with ADHD are not all exactly alike in either their strengths
or their difficulties. (See Chapter 2.)
11. Most children and adults who have ADHD also have difficulties
from one or more co-occurring disorders at some point in their life
times. The incidence of learning disorders, anxiety and mood dis

orders, sleep disorders, obsessive-compulsive disorder, substance
use disorders, and autism spectrum disorder is considerably
higher among those with ADHD than in the general population.
Sometimes the co-occurring disorder is recognized and the ADHD
is not. (See Chapter 7.)
12. Medication treatments do not cure ADHD, but for about 8 of 10 chil
dren and adults with ADHD, carefully managed medication treat
ment significantly improves ADHD symptoms for those parts of the
day when the medication is active. These medications are not like an
antibiotic that may cure an infection; they are more like eyeglasses
that improve vision only while they are worn. (See Chapter 10.)
Central Mystery of ADHD

Despite the many differences among children and adults with ADHD,
there is one similarity shared by virtually all of them. Although they
have considerable chronic difficulty in getting organized and getting
started on many tasks, focusing their attention, sustaining their efforts,
and utilizing their short-term working memory, all of those diagnosed
with ADHD tend to have at least a few specific activities or tasks for
which they have no difficulty in exercising these very same functions in
a normal or even extraordinary way.
Many children with ADHD who struggle painfully to focus on their
schoolwork and daily chores are able to focus effortlessly very well for
playing a favorite sport or video games. Many college students with
ADHD earn top grades in one or two courses for which they have strong
interest because of the content of the course or the skills and charisma of
the professor, yet they fail out of college because they are unable to sus
tain their attention and effort for many other courses required for their
curriculum. Many adults with ADHD are not promoted at work or re
peatedly lose their jobs not because they do not do many aspects of their
job quite well or very skillfully but because they are consistently unable
to awaken themselves to get to work on time or because they are exces
sively forgetful about attending to important assignments or fail to
hand in required reports accurately done before established deadlines.
Many individuals of all ages with ADHD demonstrate amazing abil
ity to recall all the details of the story line of a movie seen years earlier, or
words and music of countless songs they once heard, or random details
of long-ago incidents they observed, yet they are often incapable of re
calling what they have read or have heard just a few minutes ago. All in
dividuals with ADHD tend to have a few tasks or situations where they
demonstrate impressive or, at least, quite adequate competence in exer
cising various cognitive management skills that they are unable to exer
cise with consistency in most other activities of daily life, even though
they see the importance of doing those tasks and very much want to per
form them successfully.
Symptoms of ADHD are chronic, but in each person, they appear
with notable exceptions, usually in situations where the person has
strong personal interest in a particular task or activity or when they be
lieve that something very unpleasant for them is likely to occur very
quickly if they do not attend to this specific activity right here, right
now. Clinical observations and empirical research have consistently
demonstrated that ADHD symptoms are situationally variable and that
there is much intra-individual variability in the symptoms of this disor
der. This is the central mystery of ADHD.
A classic example of this puzzling paradox of ADHD is the situation
of Larry, a sturdy, sandy-haired high school junior who was the goalie
for his school’s ice hockey team. It happened that the day before his
evaluation, Larry had helped his team win the state championship in
hockey by blocking many shots on goal. He was an extraordinarily fine
goalie, and he was also a very bright student who scored in the very su
perior range on IQ tests. He wanted to get good grades because he was
hoping eventually to go to medical school. Yet he was chronically in
trouble with his teachers. Often they said to him, “Once in a while, you
make very perceptive comments in class that show how smart you are,
but most of the time you’re out to lunch—looking out the window or
staring at the ceiling. Occasionally, you turn in a really good homework
paper, but most of the time you don’t even know what the homework is
supposed to be.” The teachers kept asking Larry, “If you can pay atten
tion so well when you’re playing hockey, why can’t you pay attention
when you are in class? If you can work so hard to practice and stay in
shape for hockey, why can’t you show some consistent effort for your
schoolwork?”
After hearing his parents tell me about these recurrent complaints
from his teachers, Larry quietly responded,
I don’t know why this keeps happening. I’m just as frustrated and even
more worried about this than you are.... I know what I need to do and I
really want to do it because I know how important it is for all the rest of
my life.... I know I should be able to do it; I just can’t! I just can’t make
myself pay steady attention to my work for school anywhere near the
way I pay attention for hockey.
This inconsistency in motivation and performance is the most puz

zling aspect of ADHD. It appears that the child or adult with ADHD who
can show strong motivation and focus very well for some tasks should be
able to do the same for most other tasks that they recognize as important.
It appears as if this is a simple problem of lacking “willpower.” If you can
do it for this, why can’t you do the same for that and that, which are even
more important? However, ADHD is not a matter of willpower. It is a
problem with the dynamics of the chemistry of the brain.
One of my patients once told me the following:
I’ve got a sexual example for you to show what it’s like to have ADHD.
It’s like having erectile dysfunction of the mind. If the task you are faced
with is something that turns you on, something that is really interesting
for you, you’re “up for it” and you can perform. But if the task is not
something that’s intrinsically interesting to you, if it doesn’t turn you on,
you can’t get up for it and you can’t perform. It doesn’t matter how
much you tell yourself, ‘I need to, I ought to.’ It’s just not a willpower
kind of thing. (Brown 2005a)
Recent research offers considerable evidence that ADHD is not a

“willpower thing,” even though, in many ways, it appears to be a sim
ple lack of willpower. When individuals with ADHD are faced with a
task that is really interesting to them, not because someone told them
that it ought to be interesting, but just because it is interesting—because
to them at that moment it either appears to offer appealing pleasure or
seems to warn of some imminent unpleasantness that they want to
avoid—that perception, conscious or unconscious, changes the chemistry of
the brain instantly. This process is not under voluntary control.
If not under voluntary control, what does control the operation of ex
ecutive functions? The answer to that question is primarily what Nobel
prize–winning psychologist Daniel Kahneman (2011) refers to as the
“automatic system” of the human mind, a system within the brain that
he refers to simply as “System 1.” This system is not actually a structure
of the brain, a clump of tissue that can be seen on an MRI (magnetic res
onance image) as it is possible to see the cerebellum or hippocampus.
The automatic system is the constantly shifting dynamic output func
tion of neural networks that continually group and then reassemble in
different transient groupings at lightning speed to bring together infor
mation from stored memories in response to whatever perceptions,
thoughts, or imaginings arise and change moment to moment in an in
dividual’s mind.
System 1 allows us to use past experience to help us recognize and
respond to whatever we are faced with in any given moment. It is the
search engine for each individual’s massive library of information and

any related emotional valuations derived from that person’s lifetime of
experiences. The automatic system is the unconscious capacity of the
brain to respond instantly to thoughts and perceptions pulling up what
ever seems relevant from past experience to help us understand and re
spond to whatever we encounter in our thoughts, perceptions, and
interactions with our environment.
Nicolelis (2011) has demonstrated that such operations of the brain
are composed not of single strings of neurons but of large interacting en
sembles of neurons that respond to perceptions, thoughts, and imag
inings by arranging and rearranging themselves and eliciting other
neuronal ensembles to communicate with one another transiently to fa
cilitate thoughts, emotions, or actions. Within milliseconds, such en
sembles can mobilize and respond to stimulation by using low-voltage
electrical messages facilitated by neurotransmitter chemicals manufac
tured in each neuron to facilitate these interactions.
Kahneman’s (2011) discussion of System 1 recognizes that the brain
also has a second system, which he refers to as the “effortful” or “atten
tive” system. This “System 2” is a more conscious operation of brain
neuronal networks, which tend to be relatively much slower and more
deliberative, the processes invoked when we need to make comparisons
or are uncertain about what to do or how to do something that is unfa
miliar or challenging. He argues that both of these systems are active
whenever we are awake:
System 1 runs automatically and System 2 is normally in a comfortable

low-effort mode in which only a fraction of its capacity is engaged. Sys
tem 1 continuously generates suggestions for System 2: impressions, in
tuitions, intentions, and feelings... .When all goes smoothly, which is
most of the time, System 2 adopts the suggestions of System 1 with no
modification....System 2 is mobilized when a question arises for which
System 1 does not have an answer. (p. 24)
Kahneman (2011) emphasizes that System 1 is the origin of most of

what we do.
Our thoughts and actions are routinely guided by System 1 and generally
are on the mark. One of the marvels is the rich and detailed model of our
world that is maintained in associative memory....(System 1) holds the vast
repertory of skills we have acquired in a lifetime of practice, which automat
ically produces adequate solutions to challenges as they arise. (p. 416)
The main point here is that executive functions operate automati

cally most of the time, guided by unconscious activities of the brain that
are based on the specific individual’s memories and priorities; these are
shaped by previous life experiences and that individual’s current situa
tion as he or she perceives it. More information about how ADHD im
pacts these operations that shape the brain’s “googling” for motivation
is provided in Chapter 5 (“How ADHD Impacts ‘Brain Googling’ for
Motivations”).
In Chapter 2 (“A New Model of ADHD”), I provide more informa
tion about the nature, causes, and various ADHD-related impairments
over the course of the life span.
Summary
Despite controversy and considerable misinformation about ADHD
in the media, the rate of ADHD diagnosis and use of medication for this
disorder has significantly increased in the United States and interna
tionally. The most fundamental reasons for this are that 1) ADHD can
cause considerable chronic impairment and suffering for affected indi
viduals and families and 2) although medication treatments do not cure
ADHD, if appropriately administered, they can safely reduce impair
ment and improve functioning.
This chapter states 12 important science-based findings about ADHD
as complex impairment of the brain’s self-management system; these
findings are more fully explained in subsequent chapters. The chapter
also highlights the central mystery of ADHD—that those with ADHD
are able to function quite effectively when engaged in a few specific ac
tivities or tasks that interest them, utilizing those same self-management
functions that are chronically impaired for most other activities. This is
explained in terms of the brain’s “automatic system,” which is not deter
mined by “willpower.”
2
A New Model of ADHD
Executive Function Impairments
SCIENTIFIC RESEARCH OVER THE PAST 30 YEARS

has brought a major change in our understanding of the disorder cur
rently known as attention-deficit disorder (ADD) or attention-deficit/
hyperactivity disorder (ADHD). Findings from clinical and neurosci
ence studies have brought a fundamental shift from the earlier notion
of ADHD as a disruptive behavior disorder of young children to a sub
stantially new model. This new paradigm recognizes that ADHD af
fects not only young children, both boys and girls, but also many
adolescents and adult men and women. It substantially expands the
concept of attention and portrays ADHD as a complex, often inherited,
syndrome of impairments of the brain’s cognitive management system,
its executive functions. It is hoped that ADHD eventually will be re
named executive function deficit disorder (EFDD) to reduce confusion
and to recognize the full scope of what science has discovered about this
complex disorder (Barkley 2015).
Some who hear this description of ADHD as “impaired executive
functions” think that ADHD is caused by impaired executive functions.
That is a misunderstanding. When we say that ADHD is a syndrome of
impairments of executive functions, we mean only that the essential dif
ficulties—the impairments—that characterize the disorder are a cluster
11
of chronic difficulties with the brain’s self-management system. These

difficulties are the characteristics of ADHD, not the causes of the disorder,
just as severe chest pain, irregular heart rate, and shortness of breath may
be characteristics of a heart attack but are not the cause of a heart attack.
Recent scientific research has brought forth evidence that for many
people the problems of ADHD are associated with inherited differences
in the development, structure, and functioning of the brain. It is likely that
there are a variety of different physiological factors that can contribute to
various profiles of executive function impairments that characterize
ADHD. This is discussed further in Chapter 6, “How ADHD Develops,
Sometimes Gets Worse, and Sometimes Improves.”
Impairments of ADHD sometimes become apparent during very
early childhood, in preschoolers who are far more restless and impul
sive than most others of the same age. Frequently, these children have
chronic sleep difficulties, are excessively irritable, and, in some cases,
are exceptionally aggressive toward peers and younger siblings. They
are much more difficult for parents and other caretakers to take care of
and to keep safe than most other children of similar age.
For many others with ADHD, their impairments do not become ap
parent until they meet the challenges of the early years of schooling,
when they are expected to participate in structured group activities and
are challenged to learn new concepts and skills while also learning to re
late to new adults and peers of various ages. Still others do not demon
strate ADHD-related impairments until they advance further in their
schooling and must deal with multiple teachers, frequent changing of
classes, and increasing demands for more independent work in middle
and high school. For some, their parents provide such effective scaffold
ing support that their ADHD-related impairments are seen only as they
move away from home to meet the challenges of college, getting and
keeping a job, and other demands of adult life.
This new model asserts that ADHD is a syndrome of impairment of
executive functions: clusters of dynamic, interacting cognitive functions
of the brain that are critical for most aspects of self-management. Many
components of the brain are essential infrastructure for executive func
tions. These include the prefrontal cortex in the front of the brain, the
limbic circuits deep in the midbrain, the cerebellar region near the back
of the brain, and many others. Data from recent neuroscience research
have shown that the impairments of ADHD are malfunctions not so
much in any one specific area of brain but in communications between
widely distributed neural networks that support instantaneous interac
tions of various regions of the brain that activate and rapidly coordinate
countless thoughts, memories, and actions (Cortese et al. 2012).
A New Model of ADHD 13
In many instances, ADHD appears as a developmental impairment

of executive functions. This means that for many who have ADHD,
their executive functions do not mature, do not come “online,” to func
tion consistently as would be expected for most others of similar age.
Sometimes, individuals catch up with peers within a few years; in other
cases, the developmental delay persists much longer, or, if not treated
adequately, the impairment of executive functions may persist through
out the individual’s lifetime (Shaw et al. 2007, 2012).
Developmental delay is not the only way executive functions can be
come impaired. These cognitive functions can become impaired by
trauma in a head injury or by disease such as Alzheimer’s disease, but
most individuals whose executive functions are damaged by injury or
disease had adequate executive function and lose it as a result of dam
age to brain tissue. For many of those with ADHD, the executive func
tions have not developed within the usual time frame. Those with
ADHD are very significantly delayed in these specific but important
functions when compared with the vast majority of their peers. They
may have many impressive talents, but they have significant impair
ments in important aspects of self-management.
Executive functions are those capacities of the brain that allow a person
to recognize the tasks that he or she needs to do, to be motivated adequately
for doing those necessary tasks, to plan for and organize how to accomplish
the tasks, to initiate the various components of the task without excessive
delay, and to sustain effort and actions needed to complete the essential
tasks. Neuropsychologist Muriel Lezak noted, “Questions about executive
functions ask how or whether a person goes about doing something (e.g.,
Will you do it and, if so, how and when?)” (Lezak et al. 2004, pp. 35–36).
In early childhood, only very elementary aspects of executive functions
are developed. Examples include learning to brush one’s teeth, to dress
oneself, or to pick up one’s toys without direct step-by-step instruction
from an adult each time. Throughout childhood, adults, older siblings, or
other individuals provide considerable direct instruction in each instance
to help the child successfully execute such task sequences. Initially, parents
or other individuals facilitate this learning by doing the task for the child;
they then progress to talking the child through the task, assisting as needed.
Eventually, typically developing children gradually learn to do such tasks
with a simple reminder to start the sequence. With similar parental guid
ance, most children gradually learn to interact appropriately with others, to
safely cross a street, to ride a bike, and, eventually, to drive a motor vehicle.
Similar sequences of learning within the scaffolding of direct mod
eling, close supervision, and practice can enable most children to de
velop their capacities to self-manage a rapidly expanding progression of
tasks of self-care, social interaction, and academic skills required for

daily life. As the child develops the capacity to initiate, self-manage, and
adequately execute the progression of such tasks, he or she is demon
strating development of very elementary stages of executive functions
and is progressively building the foundation for learning additional
skills to self-manage the tasks of daily life.
Various models have been offered to describe the cognitive functions
involved in executive functions (Barkley 2011, 2012a, 2015). Figure 2–1
is one such model. It includes six clusters of related cognitive functions
that interact dynamically for self-management. The boxes of the dia
gram do not represent parts of the brain; rather, they show various types
of functional activities of the mind, each of which involves multiple as
pects and neural networks of the brain. Explanation and elaboration of
these clusters are provided in the following subsections.
Executive Functions Impaired

in ADHD
Activation: Organizing, Prioritizing,
and Activating to Work
Many persons with ADHD report chronic difficulty in organizing their
stuff. Students with ADHD often have excessively disorganized note
books, desks, lockers, and living space, unless someone else is helping
them keep their things organized. Adults with ADHD often report
chronic difficulty in keeping track of their bills, correspondence, finan
cial records, clothing, and household supplies.
Others with ADHD have no difficulty in organizing their stuff, but
they have chronic problems in prioritizing and organizing their time
and their work. A young student may spend hours on a Tuesday eve
ning making an elegant cover for a social studies report due the next day
without attending to the fact that the report itself has not yet even been
started. Often, individuals with ADHD say that if they have many tasks
to do, all those tasks seem equally important; they find it very difficult to
assign priorities, to determine which task needs to be done first, second,
third, and so on. For example, they might find it difficult to decide be
tween cleaning out a cluttered closet and getting started on preparations
for a dinner they need to have ready for guests in less than hour.
Even when they are able to establish clear priorities, persons with
ADHD too often delay starting tasks they need to do. One example is an
attorney who sought consultation.
Executive functions
(work together in various combinations)
Organizing, Focusing, Regulating Managing Utilizing Monitoring and

prioritizing, and sustaining, alertness, frustration and working self-regulating
activating and shifting sustaining effort, modulating memory and action
to work attention to and adjusting emotions accessing recall
tasks processing speed
1. 2. 3. 4. 5. 6.
Activation Focus Effort Emotion Memory Action
FIGURE 2–1. Executive functions impaired in attention-deficit/

hyperactivity disorder.
Source. Brown 2001.
All my life, I’ve had trouble getting started on my work when I have to
work by myself. I have no trouble talking with clients or working with
our secretaries or other attorneys, but when I have paperwork to do, I
have great difficulty getting started.
Twice each week, I set aside several hours to do paperwork that I
want to get done and need to get done because I’m not going to get paid
until it’s completed. I’m in my office with the door closed. Nobody is
bothering me, and the secretary can cover the phone. I have all the stuff
I need right in front of me, and I don’t touch it. I turn on my computer
and check my e-mails. Then I write a few notes to various people. Then
I get on a couple of news sites to see what’s going on in the world. Then,
magically, a video game appears on my screen, and I spend several
hours playing that. Then I go home, and my work is still not done. I get
home, get something to eat, watch a little TV, and then, about 10 P.M., it
occurs to me, “Oh, my God. I’ve got that report to get done tonight. If I
don’t get that in by 8 A.M., I’m going to be in very serious trouble at work
tomorrow morning.” Then I finally get started on my home computer,
work consistently until 2 or 3 A.M., and produce an excellent report. But
that’s a hell of a way to live.
Everybody struggles with deadlines once in a while; individuals

with ADHD often cannot get started on a task until it becomes an emer
gency. They have much difficulty in motivating themselves to get
started on many tasks unless that specific task is especially interesting to
them, or unless they expect that something very unpleasant will happen
to them very soon if they do not get the task done right here, right now.
Focus: Focusing, Sustaining Attention on Tasks,

and Shifting Attention When Needed
For persons with ADHD, it is often difficult to focus on a specific task
and sustain their attention on that task. When they are reading or writ
ing or participating in a conversation, class, or meeting, their minds re
peatedly drift off to think of other things that have nothing to do with
the focus they are trying to keep. They work at the task or follow the
conversation for a bit, and then someone drops a pencil and they must
look to see where the pencil landed, and then they get back to the task. A
few moments later, they are thinking about some TV show they recently
watched, then after a few minutes they get back to whatever they were
doing. After a few more minutes, they remember a telephone conversa
tion they had a few hours ago. After a few minutes, they regain focus on
the task, and then their eyes drift over to look out the window as anyone
else does from time to time, but they are likely to look longer to check
out the traffic and the cloud formations and pedestrians walking down
the street. They resume their focus on the task, and they then start won
dering, “When is this damn thing going to be over?” As they start think
ing about what they are going to do when this task is finished, they may
think, “I need to call Helen when I get home,” or “I wonder what we’re
having for supper tonight.” Or “I still haven’t heard anything back from
Jack about the e-mail I sent him last week. Wonder what’s up with him?
When was the last time I saw him? Oh, yeah, we went to see that movie
together. That was a pretty good movie. When I get home, I should
check out what’s playing this weekend; maybe we can go catch another
good one.” People with ADHD often say that in their mind it is as
though they have five different TV stations, all coming in on one chan
nel at the same time. It is very difficult for them to separate the signal
they are trying to focus on from the mental “noise” that accompanies it.
Addressing this focusing problem in ADHD does not mean locking
attention continually on just one specific item. It is not like holding a
camera still to focus on just one object to take a picture. It is more like
what we do when we focus on our driving. When driving a car, we do
not simply stare at the bumper of the car in front of us. We look at that
car, but we also look down the street to notice that the traffic light is
changing from green to red, so we move a foot from the accelerator to
the brake. We also gaze frequently at the rearview mirror to see what is
coming up from behind, and we watch a truck that is backing out of a
driveway into the street. At the same time, we notice a few pedestrians
running across the street to catch an approaching bus, and we plan to
get into the next lane so we can prepare to make a left turn at the next
corner. While doing all this, we may be thinking about what we are go
ing to buy when we get to the grocery store.
When focusing on our driving, we are shifting the focus of our vision
and attention across multiple aspects of what is around us as we move
along the street, keeping in mind what we notice as potentially impor
tant and ignoring distractions that are not currently significant. If we
notice any objects or movements that are unusual or may create a prob
lem, our attention focuses instantly to reassess that situation while we
still keep in mind the larger shifting picture of where we are and what
we are doing as we drive the car down the street.
Effort: Regulating Alertness, Sustaining Effort,

and Adjusting Processing Speed
Many people with ADHD complain of chronic difficulties in regulating
their sleep and alertness. They might say the following:
Often, I stay up a lot longer than I really want to or should because I’ve
found that if I try to go to bed before I’m really exhausted, I can’t shut my
head off; I just keeping thinking about stuff. So I stay up late reading or
watching TV or using the computer until I’m fully exhausted, and then I
can fall asleep without much trouble.
Yet these same people often complain that once they fall asleep, they
tend to sleep like dead people and have much difficulty in waking up.
Often, they report that they are unable to hear and respond to an alarm
clock or that they hit the snooze button repeatedly or simply turn off the
alarm and go back to sleep unless they have someone who is available
and willing to help them get up and out of bed. Without such help, they
are quite likely to show up late or completely miss school, work, or any
other commitments that they actually want to and need to be present for.
During the day, they are usually OK so long as they are walking
around or talking a lot. But if they have to sit still for a long time to read
or listen to a lecture or attend a class or meeting, their eyelids tend to get
heavy, and they feel drowsy as they fight off falling asleep.
Another struggle for many with ADHD is illustrated by a university
student who was a runner on the track team:
My mind is a great sprinter, but it’s a lousy distance runner. If the task I
have to do is something where you can go all out and finish it in one
chunk, I’m fine. But if it’s a longer-term project, something you can’t
complete in one quick chunk, something you have to do a bit at a time,
day after day, that’s much more difficult for me. Typically, either I rush to
get the damn thing done as quickly as possible or I just put it aside, say
ing I’ll get to it when it becomes more of an emergency.
One particular dilemma for many individuals with ADHD involves

expository writing. If they must write a book report or an essay or a long
letter or report, they often get stuck. They may have many good ideas to
write about, but they have a lot of trouble organizing what they are try
ing to write and figuring out which are the most important points,
which are more subordinate, which are supportive, and which are irrel
evant. They have a good deal of trouble organizing their ideas, and they
tend to be very slow arranging ideas in sentences and paragraphs. One
person described this as somewhat like having a good computer and a
very slow modem. Their processing speed for writing is snail-like. It is
painfully slow for them to get their ideas out on a page. Often, what they
finally write is quite well done, but for many, the completion of the writ
ing task is so burdensome that they keep putting it off until the very last
minute, and they may not complete it at all.
This difficulty with expository writing is just one example of slow
information-processing speed. Many individuals with ADHD find that
it takes them much longer than others of comparable age to process and
act on information. A first-grader with ADHD may need twice as long
as classmates to copy two simple sentences off the blackboard. High
school or college students with ADHD may have much more difficulty
than classmates in taking adequate notes from a teacher’s lecture. They
may be struggling to write down important points from the first sen
tence they heard while others are already completing notes on the third
or fourth point being mentioned.
Some of these students are very quick, perhaps even “hyper” in their
actions and physical movements, yet they tend to be quite slow in trans
forming information they have heard or even their own thoughts into
sentences and paragraphs. They may process information very well but
quite slowly.
Emotion: Managing Frustration

and Modulating Emotions
Although current diagnostic criteria for ADHD do not include any
items related to managing emotions, there is an increasing body of re
search indicating that many people with ADHD have much difficulty in
managing their emotions, particularly impulsive emotional reactions to
frustration (Barkley and Fischer 2010; Surman et al. 2013). Often, they
complain of chronic difficulties in managing frustration, anger, disap
pointment, desire, or worry. They speak about how these emotions take
over their thinking in the same way a computer virus invades a hard
drive, making it impossible for them to think of anything else. Some in
dividuals with ADHD struggle to manage a wide range of emotions;

others are more vulnerable to difficulties with just one or two, such as
anger or worry. Two different examples of persons with ADHD who re
ported chronic difficulties with managing a variety of emotions are pre
sented here.
A salesman told of his experience having a late lunch in a local diner.
There weren’t many people in the diner; it was late afternoon. I was in a
good mood eating my soup, when a guy sitting in the booth behind me
began chewing his sandwich very loudly, “chomp, chomp, chomp!”
There was something about that noise that was driving me nuts. It in
vaded my mind like a computer virus invades a hard drive—taking up
all of the space. All I could think of was that noise! My fist clenched, and
I was seriously thinking about smacking this guy in the mouth. I didn’t
do it; I didn’t want to get arrested. Then after a few minutes, he was still
making the same noise, but at that point it didn’t bother me anymore.
That sort of thing happens to me often. Some little frustration that on
a scale of 0 to 10 most people would rate as a 0 or a 1 can hit me like a 7
or an 8 or a 9! I feel like punching somebody or breaking something.
Then, in just a couple of minutes, it usually goes away.
He then went on to say,
It’s not always like that. Today I was walking down the hall at work, and
a friend of mine who works in another department came around the cor
ner and was walking toward me while he was reading some papers. I
hadn’t seen him for a long time, so I stopped and said, “Hi, how’ve you
been?” He looked up, said, “Hi,” and then put his head down and kept
on walking. Most people would blow that off in a second. They’d just
say, “He’s probably in a hurry to get to a meeting or something. We can
talk later.” Not me! That happened at lunchtime and I didn’t get any
thing done all afternoon. I spent the whole afternoon thinking, “Did I do
something to piss him off?” Or maybe I offended somebody in his de
partment, and they’re all mad at me. Or maybe I’m just a person nobody
likes, and nobody will tell me about it.
Other people with ADHD do not have problems with emotions, but
they do have problems when they get an idea about something they want
to get, something they want to buy, or something they want to do. They get
the feeling “I have to have it now!” And they do everything they possibly
can to get it now. It does not matter to them how much the item costs, or
how much it is going to make a problem for them or for someone else, or
whether they are using time or money now for this item when they know
they need to use the time or money for something else that is more impor
tant tomorrow. They just do everything they can to get whatever it is they
feel they must have now. And they keep that up until either they get it or
they hit a brick wall. But even if they get it, often they are not satisfied be
cause soon they are on to something else they want.
Some others do not have problems with wanting something imme
diately, but they worry a lot. One woman described an experience driv
ing on an expressway:
I was in the left lane driving along next to the Jersey barrier, and there was
an 18-wheel truck cruising in the lane beside me. He started to move over a
little toward me; he didn’t get into my lane, but it got me to thinking—what
would happen if he didn’t see me and pulled into my lane and squished me
and my car? Soon I wasn’t just thinking about it; I was running a very vivid
movie in my head. I pictured how he could smash into my car and squish
me against the Jersey barrier. I thought of how the car would be crumpled
and sharp pieces of metal would be sticking into me and I would be bleed
ing to death. And the truck would be dragging the car along against the bar
rier, and then it would jackknife, and we’d be getting hit repeatedly by other
cars and trucks. And there would be a massive traffic jam, and it would take
a long time for the rescue squad to get there to cut me out of the car. And by
the time they got me out, I would have bled to death; they would have to
call my family and tell them I was dead. All this was running in my head
while I was trying to drive my car 65 miles an hour down the expressway!
That sort of thing happens to me a lot, where everything is going along fine
and I start thinking, “What if this happened? Or what if that happened?”
It is not that everyone with ADHD has all of these problems with emo
tions, but many have at least one or two of them. Whether it is getting really
irritated about some little thing, or thinking too much about having had
one’s feelings hurt by someone, or getting that intense feeling of “I’ve got to
have it now!” or wondering “What if this or that might happen?”—in each
case, that emotion can gobble up all the space in the person’s thoughts like
a computer virus can gobble up all the space on a hard drive. And it is very
hard for those people to put the emotion into perspective, into the back of
their minds, and move on with whatever they need to do. For a while, the
problematic emotion just floods their brain.
This flooding with an uncomfortable feeling is not the only way
emotions are problematic for persons with ADHD, but managing such
emotions is one aspect of executive functions that tends to present
chronic difficulties for many with ADHD. Other ways emotions are in
volved in ADHD are discussed in Chapter 5 (“How ADHD Impacts
‘Brain Googling’ for Motivations”).
Memory: Utilizing Working Memory

and Accessing Recall
When asked “How is your memory?” people with ADHD often answer
that they have a very good memory, the best in their family; they can re
member things that no one else in the family can recall. They may be
able to tell in detail the entire story line of a movie they saw just once
more than 10 years ago. Or they may recall almost every play that was
run when they watched the Super Bowl 2 years ago. They may be able to
recall all the music and all the words of every verse of hundreds of songs
that were popular many years ago. Yet despite their having excellent re
call of some things from a long time ago, often they are unable to recall
something that happened just a few minutes ago.
The problem with memory in ADHD is generally not with long-term
storage memory. The difficulty is usually with short-term working
memory. Working memory is what helps us to keep one thing in mind
while we are doing something else. This is the aspect of memory that
makes it difficult when you call to get a phone listing and do not have
paper or pencil to write it down. In that situation, many persons with
ADHD tend to mix up the numbers, unable to keep them in mind long
enough to dial the call correctly. Working memory is what fails us when
we go into another room to get something and then cannot remember
what we came to get. It is what causes a problem when we go down
stairs to get something needed to do a project and then see something
down there that is interesting or that needs doing, and soon we get in
volved in project number two, completely forgetting that we had been
working on project number one upstairs and needed to get it done.
Working memory failure is involved when a student raises his or her
hand to give an answer to a question the teacher has asked the class and
then has to wait because the teacher calls on someone else first. Mo
ments later, when the teacher asks, “Yes, what were you going to say?”
the student has to say, “Sorry, I forgot what I was going to say, and now
I’ve even forgotten what you were asking us. Could you repeat the
question, please?” This is the same problem that may afflict a person
who is thinking of five things he or she needs to take along when he or
she goes out and then half an hour later is able to remember only one of
the five items and cannot recall the other four, even to save his or her life.
Many individuals with ADHD have memory problems with read
ing, especially if what they are reading is not particularly interesting to
them. They can read pages of text and understand every word as they
read it, yet a few minutes later they do not have the foggiest idea of what
they have just read.
But there is also another way in which working memory often fails
persons with ADHD. Working memory is the search engine for the
brain, instantaneously pulling up various thoughts, memories, and im
ages that may be relevant to what we are noticing or thinking about or
doing. Often, students with ADHD will study the night before an exam
and then have someone quiz them on what they have studied. They may
know all the answers quite well and go to class the next day expecting to
get a very good grade on the exam. But as they are taking the exam, a lot
of what they knew so well the night before just evaporates and they can
not pull it out of their head when they need it for the exam. However, a
few hours or a few days later, something may jog their memory, and all
that they were unable to recall earlier comes back without any further
studying. It is as though their brain’s search engine was simply unable to
recall what was needed when it was needed. The problem is not that they
failed to learn the information. They learned the information but were
unable to retrieve it when they wanted it.
Action: Monitoring and Self-Regulating Action

Activity level varies a lot among persons with ADHD. Some individuals
are quite hyperactive and impulsive when they are very young, con
stantly wiggling around, finding it hard to sit still or to remain seated, or
to stop talking and making various noises. For most, that hyperactivity
and impulsivity gradually settles down as they get into late childhood
or early adolescence. There are some who remain very hyperactive even
into adulthood. It is as though they have only two speeds: full speed
ahead or asleep, without much in between. They seem unable to stop
talking or wiggling or playing with various objects in their hand. Many
with ADHD are like most others of the same age, sometimes active,
sometimes not. There are some who are quite sluggish and tend to be
like “couch potatoes.” It practically takes dynamite to get them moving
to do anything.
Being too fast or too slow in moving around is not the only type of
action that is often problematic in persons with ADHD. Other problems
include excessive physical activity, excessive verbal activity, or exces
sive impulsivity, jumping into action without adequately considering
the potential consequences. Many tend also to be too quick to speak or
too fast to jump to conclusions. Often, they act impulsively without con
sidering potential consequences, or speak out as though they have no
filter, or are simply rude. This may take the form of interrupting others
who are speaking or otherwise occupied, blurting out whatever they
want to say regardless of how impolite or intrusive it might be. Some
times, it might involve being harshly critical of another person’s appear
ance or making remarks without considering how they might be hurtful
or provocative.
For children, problematic action may mean crossing a busy street
without first looking for oncoming traffic. For adults, it may involve
driving too fast for road conditions or frequently exceeding posted
speed limits simply because one is in a hurry or passing other cars in a

dangerous way because one is impatient with those driving slowly. Or it
may be shooting off one’s mouth with a harsh comment about someone
else without considering how hurtful the words may be. For adults, it
may be making a quick decision to buy something that looks appealing
without considering whether they can really afford to pay for it.
Often, what is lacking when taking an action is adequate monitoring
of oneself and the situation—noticing when someone else is busy or
paying attention to road conditions and traffic rules while driving—
looking at the context or the bigger picture rather than simply acting on
whatever feeling or inclination occurs at the moment. Often, persons
with ADHD report that they are told by others that they do not know
when to stop monopolizing a conversation or that they come across as
though the words they want to speak are always more important than
those of anyone else. In other situations, the problem may not be so
much monitoring the present situation but simply acting without suffi
cient forethought about what effects may follow later.
This self-monitoring involves more than the moment-by-moment
monitoring required in crossing a busy street, participating in a conver
sation, or driving a car. It also involves longer-term self-monitoring,
such as filling the gas tank before the car is running on fumes, keeping
track of how much money one has in the checking account before writ
ing a check, and considering how many commitments one has for the
coming week before deciding whether to accept an invitation or take on
an additional errand or project. It involves remembering to respond to a
phone call or to thank someone for a gift received. For students, self
monitoring includes keeping track of when a longer-term assignment
will be coming due so it is not left undone until the last minute or mak
ing the time to begin studying for an exam early enough to be ade
quately prepared. Many of these examples illustrate how monitoring
one’s actions is closely intertwined with other executive functions such
as utilizing working memory, setting priorities, and getting started.
Dynamic Interactions
of Executive Functions
Although the model of executive functions depicted in Figure 2–1
shows six separate boxes, each with its own label, these functions are
not separate unitary functions. They are not like height, weight, or
blood pressure, each of which is a unitary variable. Each of these clus
ters should be thought of as a collection of related cognitive functions
that interact in various ways simultaneously. Think of carrying on a con

versation, driving a car, or preparing a meal. Each of those tasks requires
a flow of quickly recalling, organizing, and prioritizing thoughts and
plans and aims and actions; getting started while monitoring what is go
ing on; and making small or substantial changes in timing and actions
according to the quickly changing needs of the moment.
Most of the time, these dynamic processes are not separately de
liberated and thought out piece by piece. They flow unconsciously—
unconscious not in the psychoanalytic sense of repression but in the
more modern sense of automaticity. They move so quickly that there is
no time for deliberating unless the action must be stopped because of
some unforeseen problem or interference that disrupts the process and
requires more deliberation before further action. Examples are when a
conversation takes a totally unexpected turn or is interrupted by some
unrelated event, when a driver is suddenly confronted with another ve
hicle cutting into traffic or unexpectedly slowing down or when an
emergency vehicle’s siren requires pulling to the side of the road, and
when the cook suddenly notices that a pot is boiling over while a ring
ing telephone demands attention.
This automaticity is seen in the seamless movements of a basketball
player who dribbles the ball down the court and approaches the basket
to attempt a layup shot. That player is not saying to himself, “Now I
move my left foot forward, next I move my right foot forward, now I
move to the left around this defender, now I drop my left shoulder and
lift the ball with my right hand, now I turn my head slightly and push
the ball up to make the shot.” Those movements and many others are in
tegrated and executed quickly and smoothly in sequence, while at the
same time the player adjusts to changing positions and movements of
other players encountered in the approach to the basket. Executive func
tions operate in dynamic interaction, usually without much conscious
thought or deliberation.
Summary
In this chapter, I describe a six-factor model of the brain’s self-management
system, its executive functions. These factors are 1) activation, organiz
ing, prioritizing, and activating to work; 2) focus, focusing, sustaining,
and shifting attention to tasks; 3) effort, regulating alertness, sustaining
effort, and adjusting processing speed; 4) emotion, managing frustration
and modulating emotions; 5) memory, utilizing working memory and
accessing recall; and 6) action, monitoring and self-regulating action.
These executive functions work together dynamically via rapidly re

grouping interactive neural networks of the brain.
These six clusters of executive functions are those capacities of the
brain that allow a person to recognize tasks they need to do, to be mo
tivated adequately for doing necessary tasks, to plan and organize how
to accomplish tasks, to initiate the various components of the task, and
to sustain effort and actions needed to complete essential tasks. Exam
ples in the chapter illustrate how developmental delays related to
ADHD can impair these functions, which operate unconsciously.
3
Differences Among
Persons With ADHD
WHEN LOOKING AT THE LIST OF SYMPTOMS OF

attention-deficit/hyperactivity disorder (ADHD), many people recog
nize problems that are not uncommon. They exclaim, “Oh, I have all these
problems too. So does everybody else. How can this be any big difficulty
to anyone?” The answer to that question is simple. It is a matter of how
often and how much these difficulties interfere with the person’s life—
how much these problems are impairing to the person. All of the symp
toms that characterize ADHD are difficulties everyone has sometimes.
Persons are legitimately identified as having ADHD only if they experi
ence significant and persistent impairment from ADHD syndrome con
sistently for a long time.
ADHD is not an all-or-nothing category like pregnancy, where one
either is or is not pregnant, with nothing in between. It is more like de
pression. Everyone has some times when they feel sad and unhappy,
but we do not diagnose someone as clinically depressed simply because
he or she has been unhappy for a couple of days. It is only when a per
son has been seriously impaired by depressive symptoms that have per
sisted for a significant period of time that he or she may be diagnosed
legitimately as being clinically depressed. Persons with ADHD experi
ence much more persistent and significant impairment than do persons
who do not have ADHD.
27
Persons with ADHD have similar impairments and share a similar

cluster of symptoms, but people with ADHD are certainly not all alike,
even in aspects of their ADHD-related impairments. There are many
ways in which persons with ADHD differ from one another. This diver
sity among groups of persons with a similar diagnosis is increasingly
being identified in psychiatric research as important for recognizing
how various traits identified as problematic tend to vary within the nor
mally functioning population as well as within any specific diagnostic
category (e.g., Marquand et al. 2016). In this chapter, I describe eight of
the many ways in which those with ADHD may differ from one another.
There are two other important differences among those with ADHD that
are addressed in subsequent chapters: the impact of age differences is
described in Chapter 4, “Ways ADHD Can Impair Functioning at Vari
ous Age Levels,” and differences created by co-occurring disorders are
discussed in Chapter 7, “How and Why Other Disorders Often Co-occur
With ADHD.”
Differences in Severity
of Impairment
Even within the range of impairment sufficient to warrant diagnosis,
ADHD comes in small, medium, and large. Persons with this disorder
vary in terms of how much their ADHD problems interfere with or re
duce the quality of their daily life—how they are able to work in school
or do their job or get along with their family and other people.
For some individuals, their problems with ADHD symptoms are rel
atively mild, clearly more problematic than for most persons of similar
age yet not very noticeable except in certain situations or only to the
people closely involved with them on a daily basis. For example, these
individuals may perform well in most aspects of their jobs, yet their per
sonal finances may be disorganized because of chronic inability to keep
track of their bills and their taxes and a tendency to make many impul
sive purchases that exceed their financial means. A person who is a pro
ductive worker in his business may be a careless and impulsive driver
who speeds excessively and routinely violates basic rules of the road,
endangering himself and others.
For others, impairments of ADHD are moderate, often causing sig
nificant frustrations and difficulties in their studies or employment and
disrupting their interactions with others, yet they still function in many
situations without being severely incapacitated. A student may earn
high grades in a few classes in which she has strong interest while ig
Differences Among Persons With ADHD 29
noring assignments and violating attendance requirements in so many

less appealing courses that she is forced to withdraw from a course of
study because of an excessively low grade point average. Yet that same
student may be extremely efficient and reliable in working at her part
time job in a restaurant.
Unfortunately, there are also some individuals whose ADHD-related
impairments are much more obvious, more pervasive, and more de
structive. Because of their severe ADHD-related impairments, they ex
perience repeated failures in school and are unable to maintain steady
employment because of excessive absences and lateness, failure to com
plete work tasks on time, and chronic forgetfulness about instructions
from supervisors. They may be in chronic conflict with coworkers, fam
ily, and friends, frustrating and annoying others so much that many of
their relationships are damaged or disrupted by their ADHD-related
tendencies to be too outspoken or to neglect commitments to others.
For some persons, their ADHD impairments are worsened by com
plicating factors such as excessive drinking or drug use, episodic depres
sion, or repeated poor choices of friends or partners. Some others suffer
persisting economic misfortunes or multiple illnesses or injuries. Others
struggle with the complicated and persisting burdens of caring for var
ious family members impaired by mental, physical, or economic diffi
culties. However, some are also fortunate in developing successful
relationships with a partner, employer, or mentor who is able to provide
resources and support to help them develop their strengths despite the
impairments of ADHD. And some sooner or later are able to obtain and
benefit from effective treatment that helps to alleviate their ADHD
symptoms while they develop their personal strengths.
Differences in Intensity of
Hyperactivity and/or Impulsiveness
For many decades, the syndrome now identified as ADHD was under
stood simply as a chronic problem with disruptive behavior, mostly in
little boys who could not sit still, would not behave, and were far more
careless and annoying to parents and teachers than most other boys of
the same age. Common stereotypes of those with ADHD characterize
them as constantly restless and in perpetual motion and quick to speak
or to act impulsively, without enough attention to potential conse
quences. Early descriptions of the disorder did not say much about it as
a problem with attention. In fact, it was not until 1980 that the Diagnostic
and Statistical Manual of Mental Disorders (DSM) introduced the term
“attention deficit” into its name for this disorder and recognized that it
can occur with or without excessive hyperactive behavior (American
Psychiatric Association 1980).
More recent research-based understandings of ADHD recognize
that many of the individuals diagnosed with ADHD have never had
any significant behavior problems and have never been hyperactive. On
the contrary, a large number of those with ADHD tend to be more slug
gish and struggle to mobilize themselves to do what needs to be done.
Some researchers have suggested that those whose attentional prob
lems are characterized by considerable sluggishness ought to be seen as
having a disorder distinct from ADHD (Barkley 2015). However, per
sons in this more sluggish group seem to be just a more extreme variant
of the predominantly inattentive type of ADHD.
Even individuals who are quite impulsive and hyperactive during
early childhood usually tend to become much less “hyper” and impul
sive as they enter later childhood or early adolescence. Typically, how
ever, their attentional difficulties persist or sometimes increase as they
encounter the increasing demands for self-management that emerge
and multiply from mid-adolescence and throughout adulthood. How
ever, impulsiveness is not limited to quick movements and actions.
Many individuals with ADHD who are not too quick to speak or act re
port that they are often impulsive in the way they think, that they tend
to be too quick to jump to conclusions.
Differences in Age at Onset

of ADHD Symptoms
For many years, and still in some parts of the world, ADHD has been
understood as a problem seen only in young children. In DSM-III, it was
noted that the average age for onset of ADHD symptoms “is typically
by the age of three, although frequently the disorder does not come to
professional attention until the child enters school” (American Psychi
atric Association 1980, p. 42). Subsequent editions of DSM stated that at
least some ADHD symptoms had to have been noticed by age 7 years in
order for the disorder to be legitimately diagnosed. Incredibly, some cli
nicians still refuse to diagnose ADHD, regardless of how obvious cur
rent symptoms might be, unless a history of early childhood problems
with ADHD symptoms can be documented by parent testimony or writ
ten teacher reports from early childhood.
After research demonstrated that a significant number of children
diagnosed with ADHD at age 12, without having shown symptoms by
age 7, tended to be fully as impaired as those with earlier onset of ADHD

symptoms (Polanczyk et al. 2010), the 2013 version of the diagnostic
manual, DSM-5 (American Psychiatric Association 2013), belatedly
modified the age at onset criterion by stipulating that at least some in
attentive or hyperactive-impulsive symptoms should be present prior
to age 12 years to warrant an ADHD diagnosis.
However, this revision of the age at onset for ADHD to age 12 re
mains inappropriate, given the fact that there are some individuals with
significant ADHD impairments who do not manifest significant symp
toms until middle to late adolescence. Research by our group at Yale
found that many adults with ADHD and high IQ did not demonstrate
significant impairments until they encountered the challenges of mid
dle to late adolescence and early adulthood (Brown et al. 2009). They
did quite well in school and at home, often being recognized as honor
students at school with the reputation for very good behavior at home
and in the community. It was not until secondary school and the in
creased demands for self-management and more independent work in
multiple classes with various teachers that the ADHD-related impair
ments of these patients became noticeable. In some cases, parents pro
vide extensive and consistent scaffolding to assist their children with
ADHD, so much so that their sons and daughters do not appear to have
any significant ADHD-related impairments until they move away from
home to attend university or to seek employment, when the scaffolding
is no longer present.
One study (Faraone et al. 2006a) compared two groups of adults
carefully diagnosed with ADHD. One group included those who met all
DSM criteria for the disorder, including the requirement of at least some
noticeable symptoms before age 7. The other group met all diagnostic
criteria except for the onset of at least some ADHD symptoms prior to
age 7 years. The researchers found that those with later onset did not
differ significantly from the early-onset group in patterns of functional
impairment, number of blood relatives with ADHD, or levels of comor
bid disorders. A subsequent study (Faraone et al. 2006c) of the same
groups of adults found that personality profiles of those with onset of
ADHD symptoms prior to age 7 years were not significantly different
from profiles of those with later onset of ADHD. It is hoped that subse
quent versions of DSM will dispense with the specific age at onset re
quirement, treating this disorder somewhat like anxiety disorders, none
of which require any specific age at onset.
Most of the executive functions impaired by ADHD do not fully ma
ture in anyone until late teens or early 20s. The infrastructure of the brain
that supports executive functions depends on a process of maturation
that includes two major components: 1) a massive proliferation of corti

cal cells in the brain that begins in mid-childhood and usually peaks
sometime around puberty and 2) a long process of pruning these increas
ing cell networks over a number of years to develop efficient circuits.
This dual process of developing the circuits and regional connections of
the brain that support executive functions is not fully completed until the
late teen years or early 20s.
Most governments do not allow children younger than 16–18 years
to drive a motor vehicle on public streets. This is not because their legs
are too short to reach the accelerator and brake. That problem could be
easily remedied by altering the design of the vehicle. The reason that the
privilege of driving is reserved for those who have reached later adoles
cence is not that younger children are too short to drive. That prohibi
tion is maintained because the brain maturation processes needed to
safely manage the complex tasks and responsibilities of driving a motor
vehicle are not sufficiently developed until late adolescence or early
adulthood.
Over the past 2 years, controversy has arisen among researchers
about whether ADHD can arise in young adulthood in persons who
showed no evidence of ADHD symptoms in childhood. This contro
versy arose from data obtained in several longitudinal research studies
of children evaluated in childhood and then followed up into their adult
years. Each study had one group carefully diagnosed as having ADHD
and a comparison group carefully evaluated and found not to have
ADHD in childhood.
One study done in Dunedin, New Zealand, identified a birth cohort
of 1,037 children born in 1972–1973; these children were followed until
they reached the age of 38 years. About 6% (61) of the children were
found to have ADHD in early childhood; the rest did not have ADHD.
At age 38, only 3 of those 61 continued to meet ADHD diagnostic crite
ria. In the total sample, 3% (31) met diagnostic criteria for ADHD at age
38 years; however, 28 of them had not been found to have ADHD in
childhood. This led the researchers to question the long-held assump
tion that ADHD always starts sometime in childhood and does not have
an initial onset during adulthood (Moffitt et al. 2015).
A somewhat similar study was done with a birth cohort sample ob
tained in Pelotas, Brazil, in 1993. At age 11 years, 8.9% (393) of that group
were found to have ADHD; the rest did not have ADHD. When the
whole group was evaluated again at age 18 years, 12.2% (492 persons)
were found to fully meet diagnostic criteria for ADHD. Only 60 of the
492 identified in childhood as having ADHD continued to have it at age
18. And only 60 of those identified as having ADHD at age 18 years had
been found to have ADHD when they were evaluated at age 11 years
(Caye et al. 2016). Here again, the researchers argued that the data sup
ported the notion that ADHD does not always begin in childhood, that
it could arise for the first time in young adulthood.
A third birth cohort study also yielded findings that challenged the
assumption that ADHD always has onset during childhood. This study
of 2,040 children was done in England and Wales starting in 1995.
Agnew-Blais et al. (2016) found that 247 met diagnostic criteria for
ADHD in childhood; of those, only 54 (21.9%) continued to meet ADHD
diagnostic criteria when they were 18 years old. Yet there were 112 in the
sample who had not met diagnostic criteria for ADHD in childhood but
did meet full diagnostic criteria for ADHD when they were adults at age
18 years. Thus, three recent longitudinal studies have independently
demonstrated that a significant number of individuals who do not ap
pear to have ADHD in childhood may have experienced initial onset of
ADHD-related impairments in their late teens or early adulthood.
One possible explanation for these findings may be found in the dis
cussion in the section “Differences in Age at Onset of ADHD Symp
toms”—some impairments of ADHD do not become apparent until the
individual meets the increased challenges of late adolescence or adult
hood, at times when parental support has been more or less withdrawn.
Faraone and Biederman (2016) have argued this view.
Yet another possibility was raised by an earlier Swedish genetic
study of 1,480 twin pairs who were studied for attentional problems at
ages 8/9, 13/14, 16/17, and 19/20. This study used both parental rat
ings and self-ratings of attentional problems and found that genetic ef
fects operating at 8/9 years tended to persist, explaining 41%, 34%, and
24% of the variance over the three later age groups, respectively. How
ever, researchers also found that new sets of genetic risk factors emerged
at ages 13/14, 16/17, and 19/20 years (Chang et al. 2013). This finding
suggests that attention problems are a developmentally complex phe
notype that may involve both continuity and emerging genetic change
across the life span.
For some individuals, their ADHD impairments do not become very
noticeable until they encounter the challenges of adolescence or adult
hood. They function quite adequately or even very well in comparison
with their age-mates during preschool and elementary school. There may
be no reason for parents, teachers, or anyone else to assume that these
children have ADHD—until they reach middle school, where they no
longer have one teacher for most of the day and they need to move from
class to class. Students now must accommodate to the different rules and
expectations of various teachers with differing teaching styles and differ
ent personalities—one who wants everyone to sit quietly and another

who solicits speaking out for many informal class discussions, one who is
very strict about deadlines for assignments, and another who is very for
giving of late papers and often does not even check to see if homework
has been completed. As the academic and social routines of school be
come more complicated and there are increasing demands for students to
keep track of their own materials in moving from class to class, to write
down multiple assignments in their plan book, and to keep track of when
assignments are due and tests will be given, many students who were
able to function well in the more tightly organized routines and closer su
pervision of earlier grades begin to show signs of inadequate develop
ment of the self-management skills needed for more independent work.
This later onset of ADHD symptoms can be compared to another
medical diagnosis. If a person is given an electrocardiogram (ECG)
while lying still on a table, the ECG strip may appear perfectly clean. Yet
if the same person is given the same test while walking rapidly or jog
ging on a treadmill with incline resistance, that person may be found to
have significant irregularities or occlusion of arteries that were not ap
parent until his or her cardiovascular system was challenged with in
creasingly stressful demands. For many persons with ADHD, the
demands of the preadolescent years are much like having an ECG done
while lying still on a table; their impairments may not become apparent
until the increased self-management challenges of adolescence or early
adulthood are encountered.
Differences in Persistence or
Remission of ADHD Symptoms
For most of the twentieth century, it was assumed that the disorder now
known as ADHD occurred only in young children and that it was out
grown in later childhood or early to middle adolescence. These assump
tions were based on observations that hyperactive children usually
became much less “hyper” sometime during that period. During those
decades, ADHD was defined primarily by hyperactivity and misbehav
ior; attentional problems were not recognized as a primary component
of the disorder.
In many countries, ADHD is still thought of as a childhood disorder
that is simply outgrown during adolescence. A study by the World
Health Organization has challenged that view. Using data from a survey
in 10 different countries as diverse as France, Germany, Italy, Lebanon,
Mexico, Colombia, and the United States, Lara et al. (2009) found that an
average of 50% of children diagnosed with ADHD continue to fully

meet DSM-IV (American Psychiatric Association 1994) diagnostic crite
ria for ADHD as adults.
Continuing to fully meet DSM-IV diagnostic criteria for ADHD, how
ever, is not a sufficient criterion to determine whether a person is still ex
periencing significant impairments from ADHD as he or she matures
into adulthood. As mentioned in the introduction, those diagnostic cri
teria were developed and tested only for children ages 4–17 years. There
are many ways in which ADHD can impair functioning in adults that are
not listed in the DSM criteria. Biederman et al. (2010a) did a 10-year fol
low-up study of boys diagnosed with ADHD versus control subjects.
They used four different categories to describe the persistence of
ADHD: 1) continued to fully meet full DSM-IV diagnostic criteria for
ADHD; 2) continued to meet half of the DSM-IV criteria; 3) showed im
pairment on a global assessment of functioning; 4) did not meet crite
rion 1, 2, or 3 but were currently being medicated for ADHD.
Using those four categories of persistence, Biederman and col
leagues (2010a) found that 35% still met full ADHD criteria; 22% contin
ued to have half of the ADHD symptoms; 15% still showed impairment
on a global assessment of functioning; and 6% did not meet these three
criteria but were still being medicated for ADHD. This yielded a total of
78% of those boys 18 years or older for whom impairments of ADHD
persisted beyond childhood. A similar follow-up study of girls diag
nosed with ADHD during childhood yielded almost identical results:
77% continued to manifest impairing ADHD symptoms into adulthood
(Biederman et al. 2012).
Subsequent research has confirmed that many, if not most, individ
uals who have ADHD with excessive hyperactivity tend to become sig
nificantly less “hyper” as they move through puberty, whereas their
inattention symptoms tend to persist and often become more problem
atic as they encounter the challenges of adolescence and adulthood,
which often bring a variety of new impairments.
A study of 500 nonreferred adults whose ADHD persisted reported
a wide range of impairments compared with 501 age- and gender
matched community adults without ADHD (Biederman et al. 2006).
Those with ADHD were more likely to have left high school without
earning a diploma (17% vs. 7%), were less likely to have obtained a col
lege degree (19% vs. 26%), were less likely to be currently employed
(52% vs. 72%), were less likely to have a good current relationship with
their parents (47% vs. 70%), were less likely to report getting along with
coworkers (47% vs. 66%), and were less likely to report stability in love
relationships and had higher rates of divorce (28% vs. 15%).
Many factors influence the level of impairment for a given individ

ual with ADHD at various points across the life span. Typically, the most
difficult years for those with ADHD are junior high, high school, and
the first few years of postsecondary schooling or work. Those are the
years when one is usually required to do the widest range of tasks with
the least opportunity to escape from tasks in which one is not especially
interested or competent. Schooling in those years generally requires that
students develop some mastery of skills in language, math, history, sci
ence, and humanities, regardless of their level of interest, competence,
or vocational plans.
Later years of schooling and employment usually allow an individ
ual to specialize in a narrower range of tasks that, hopefully, will fit bet
ter with his or her abilities and vocational interests. At that time,
individuals more proficient in processing numerical, mechanical, or sci
entific data can focus on those interests and avoid having to take courses
for which they need to write term papers. At the same time, individuals
more inclined to work with words or interpersonal relationships may be
able to utilize those skills without having to take courses that require
more advanced levels of math or science. Those who are really fortunate
may find their way into employment where they can build on their per
sonal interests and competence, leaving to others most of the tasks out
side their own range of skills and interest. Persons with ADHD usually
tend to do best when they are working at tasks that fit with their active
interests.
Another influence on level of impairment is access to rewards. For
many individuals with ADHD, motivation to do schoolwork is weak,
especially when those tasks are not intrinsically interesting to them. The
prospect of getting a good grade on a report card given out many weeks
in the future does little to spur their interest in working on classwork or
homework today. However, some of those same individuals are
strongly motivated to work with enthusiasm and sustained effort when
they can see a more immediate reward, such as a paycheck at the end of
each week. While in school, some students are satisfied to work hard for
praise from their teachers or parents, and others are motivated by con
tinuing competition with other students in their classes. For some stu
dents, however, ADHD-related impairments diminish considerably
when they get out of school and are able to find more immediate and
more salient rewards in the world of work.
A third influence on duration of impairment is the process of brain
development. In Chapter 6, “How ADHD Develops, Sometimes Gets
Worse, and Sometimes Improves,” I provide more detailed information
about brain development with ADHD, but in this discussion of persis
tence and remission, it is important to note that 20%–30% of individuals

with ADHD during adolescence no longer meet full diagnostic criteria
for ADHD by early adulthood. Recent imaging studies have shown
clearly demonstrable differences in the brain functioning of adults
whose ADHD symptoms have remitted and those whose ADHD symp
toms persist. Those with persisting symptoms showed impaired func
tional connections between the prefrontal cortex and the cingulate
cortex; those whose ADHD symptoms had cleared did not show that
impairment and those connections were no different than in other
adults who never had ADHD (Mattfeld et al. 2014).
Differences in Gender
Early studies reported that six boys were diagnosed with ADHD for ev
ery one girl identified with the disorder. This ratio was based on chil
dren brought into clinical settings such as hospitals or child guidance
clinics. Epidemiological studies that made inquiries in community sam
ples, not counting only those brought in for treatment, have reported ra
tios closer to 3:1. However, when adults are assessed, the ratio of males
to females with ADHD is closer to 1:1. This suggests that there are many
girls with ADHD-related impairments who are not identified until they
become adults and are able to come in for evaluation themselves. Per
haps this occurs because during early and middle childhood most girls
with ADHD are not as disruptive with teachers and parents as are boys.
Comparisons of samples of boys diagnosed with ADHD with girls
diagnosed with ADHD have shown no significant differences between
the genders in the symptoms they experience, in their cognitive or psy
chosocial functioning, or in the pattern of other psychological problems
associated with their ADHD (Biederman et al. 2010c, 2012; Hinshaw
2002, 2009; Hinshaw et al. 2012).
Although those studies of children included follow-up into late teenage
years, there is little systematic research to describe the impact of ADHD on
affected adult women. There is evidence that estrogen has a substantial im
pact on release of dopamine in the female brain (McEwen 1983; Thompson
and Moss 1994). There are also clinical data suggesting that varying lev
els of estrogen due to variations in different phases of the menstrual cy
cle or diminution of estrogen due to menopause may cause more
variability in levels of impairment among females than is generally seen
in males. Some adolescent and adult women report that their ADHD
impairments tend to worsen and become less responsive to medication
treatment regimens at those points in their menstrual cycle where estro
gen levels tend to be lowest. A more recent line of research has also dem
onstrated that some women without any childhood history of ADHD

experience midlife onset of significantly impairing ADHD symptoms
concurrent with their perimenopausal reduction of estrogen and that
medications often used for treatment of ADHD may help to alleviate
those symptoms (Epperson et al. 2011, 2015; Shanmugan et al. 2017).
Differences in Underlying
Temperament
Temperament is a term that describes a collection of various personality
characteristics that are biologically “built in” in each individual, some of
which can be observed in early infancy and many of which often persist
in subtle and/or blatant patterns into later years. Developmental psy
chologist Jerome Kagan described and emphasized how
each child is born with a profile of temperamental biases...that creates

initial tendencies to be vocal or quiet, vigilant or relaxed, irritable or
smiling, and energetic or lethargic with regard to particular events or sit
uations. Parental behaviors, sibling rivalries, friendships, teacher atti
tudes, emotional identifications with family, ethnic class, religious or
national categories, and even the size of the community during the
childhood years combine with a host of chance events to sustain, or
more often to alter, the relative strength and exact form of the traits the
early biases produced. (Kagan 2010, p. 60)
Contrary to stereotypes, there is no one specific temperament pattern

that characterizes all individuals with ADHD. Studies of personality
traits in children with ADHD have recognized considerable heteroge
neity within which several distinctive profiles have been identified
(Karalunas et al. 2014; Martel et al. 2010; Nigg et al. 2004). One group
tends to be characterized by low levels of extroversion, more shyness,
and only mild hyperactive or impulsive traits, as well as less difficulty
with attentional control, compared with other ADHD types. Another
group is more outgoing, with higher levels of energy and impulsivity, as
well as more high-intensity pleasure seeking and activity. A third group
exhibits considerable impulsivity, with more difficulty in attentional
control and poor self-control, as well as higher levels of anger and irri
table behavior. Another group, less numerous, is characterized by more
obsessive or perfectionistic characteristics.
Three of these different types were found to reflect unique basic dif
ferences not only in temperament but also in basic aspects of physiolog
ical functioning that are identified with persisting patterns of cardiac
activity and respiration, as well as with different patterns of functional

brain connectivity between the amygdala and other specific areas of the
brain. The types also differed in the likelihood of having onset of an ad
ditional psychiatric disorder within 1 year of initial evaluation (Karalu
nas et al. 2014; Martel et al. 2010; Nigg et al. 2004). These studies indicate
that these categories based on basic physiological patterns may offer a
more reliable and useful way to characterize different types of ADHD
than do the present diagnostic subtypes.
Differences in Cognitive Abilities

Many people believe that individuals who are very bright cannot have
ADHD. They assume that strong intelligence will protect one from en
during such problems. That is not true. Several studies (Antshel et al.
2007; Brown et al. 2009, 2011a) have demonstrated that some persons
with very high IQ experience significant impairments from ADHD.
Clinical experience also shows that those impairments are sometimes so
severe that despite very high IQ scores, some individuals are not able to
complete college or even high school studies and may not be able to get
and maintain a job.
In contrast, some have claimed that all persons with ADHD tend to
be exceptionally bright, as though having the disorder provides them
with special gifts of intelligence, creativity, or ambition, for example.
That claim makes sense only if it is rephrased to state that some persons
with ADHD have exceptional talents that they are able to deploy in spite
of their ADHD impairments. Many of the patients that I have seen in my
years of practice are extremely impressive in their gifts and accomplish
ments. And some, as a result of their struggles with ADHD, have devel
oped a helpful perspective on themselves and various aspects of life.
However, there is much evidence that ADHD, which is defined by sig
nificant impairments, does not confer on anyone superior intelligence
(Brown 2013). Most of those whose intelligence is very remarkable see
their ADHD as a burden that has made life more difficult for them, not
as a blessing.
The fact is, ADHD is not positively or negatively correlated with IQ.
Some persons with ADHD have very superior IQ, some have average
IQ, and some have IQ scores at the low end of the IQ spectrum. In my
own clinical practice, I have treated many very successful men and
women with ADHD who were business executives, physicians, attor
neys, scientists, and Ivy League university professors, people who were
extremely bright and were quite successful in many aspects of their
schooling and careers and who, despite their impressive intelligence,

struggled with significant ADHD impairments. I have also treated
many skilled athletes and tradespeople and teachers and managers and
nurses and chefs and firefighters and salespeople and office workers
and others whose intellectual abilities ranged from extremely high to
considerably lower. ADHD is not found exclusively at any one point in
the wide range of IQ.
Some very bright students with untreated ADHD are able to get into
college but then drop out or are forced to withdraw because of inability
to complete assignments by deadlines, to prepare adequately for tests,
and to get themselves regularly to their classes. Some of those very
bright students who do poorly in school because of their ADHD might
be compared to a car with a powerful, high-horsepower engine that has
a defective transmission. The power can be generated, but the vehicle
lacks the means to transmit the power from the engine to the wheels, so
the car cannot move.
One pattern often seen with very bright students who have severe
ADHD is that they do very well in some of their courses, those in which
they have strong personal interest, but they are unable to mobilize
themselves to do adequate work in courses that they find less interest
ing or blatantly boring. They may complain that the professor is a poor
lecturer who does not explain course content clearly or is difficult to lis
ten to because of a monotonous speaking style. Or these students may
complain that the content of the course is not something they will ever
need and that the curriculum should not require it. Certainly, it is true
that some courses are not very interesting and that some professors may
know a lot about their subject matter yet be unable to teach the material
in a way that students can find interesting or readily understand. Yet
most students manage to cope adequately with such courses and teach
ers, whereas some with ADHD, even those with very strong IQ scores,
find it virtually impossible to deploy their abilities effectively to meet
the course requirements.
For these bright but struggling students with ADHD, their problem
with their studies is usually not lack of ability to learn the course con
tent. It is more a problem of inadequate executive functions, lack of abil
ity to prioritize their activities, lack of adequate focus on the course
work, and inability to get started on their work early enough and to sus
tain their efforts to complete assignments by required deadlines. Some
times, those students struggle unsuccessfully to get themselves to class
regularly and on time; others too often get lost in distracting activities,
perhaps playing video games excessively or hanging out too often with
friends when they ought to be reading or doing homework. Others may
spend many hours diligently working on course work that interests

them, while simply ignoring reading and written assignments for
courses they find less interesting. Still others cannot maintain control of
their sleeping and alertness. They may stay up too late, possibly drink
ing excessively or just spending time with friends without getting them
selves into bed early enough to get up in time to attend their scheduled
classes. Such problems with lack of focus, excessive distractibility, diffi
culties in organizing and prioritizing tasks, managing sleep and alert
ness, and avoiding excessive procrastination, for example, are all aspects
of problems with executive functions characteristic of ADHD. They are
not a result of insufficient ability to understand or lack of intelligence.
In thinking about these issues, it is also important to recognize that
there are many types of intelligence and that IQ tests measure aspects of
only a few of them. In 1983, psychologist Howard Gardner published
his description of seven basic human intelligences: linguistic intelli
gence, musical intelligence, logical-mathematical intelligence, spatial
intelligence, body-kinesthetic intelligence, and the personal intelli
gences (intrapersonal intelligence and interpersonal intelligence)
(Gardner 1983). He described these various modular “intellectual com
petencies” as “building blocks, out of which productive lines of thought
and action are built” (p. 279).
In the 10th anniversary edition of his original book, Gardner joined
his view with that of Jerry Fodor, psychologist and philosopher who ar
gued that effective operation of these intelligence modules depends on
a more central processing aspect of the brain, “with diverse areas of the
nervous system participating in a wide range of activities and being (at
least potentially) in constant communication with one another” (Gard
ner 1993, p. 282). This notion of the brain’s central processing aspects
might be considered a way to think about the executive functions, those
aspects of the brain that are found to be impaired in ADHD. It offers a
way to recognize the variety of intelligences that can be seen as relatively
independent of the brain’s central processing and where deployment of
those intelligences may be facilitated or, in some situations, impaired be
cause of difficulties with the central processing system (i.e., executive
functions).
Differences in Environmental
Challenges and Supports
Although the primary factors in causing an individual to have ADHD
seem to be genetic, that is not to say that environment is uninvolved.
Genes provide blueprints for our growth and development, but en
vironment has a powerful influence on how and when potential strengths
and weaknesses programmed in our genes do or do not activate in ways
that may help one to flourish or to experience continuing struggles. Two
types of environmental factors are especially important: the intrauterine/
perinatal environment during pregnancy and birth and the external en
vironment of people and living conditions from birth onward.
Children whose mothers abused alcohol during pregnancy have
double the risk of having ADHD, and those whose mothers were alco
hol-dependent during pregnancy were found to be three times more
likely to have ADHD (Banerjee et al. 2007). Some pregnancy-related
complications, such as toxemia or eclampsia, poor maternal health, ex
ceptionally long labor, umbilical cord around the neck, or low birth
weight (≤ 2,500 g), may also increase risk of developing ADHD. One
population-based study of adults with ADHD showed that low birth
weight, preterm birth, and low Apgar scores increase the risk of ADHD,
which persists up to 40 years after birth (Halmøy et al. 2012).
As a child is growing up, some family, school, and community envi
ronments provide fairly consistent support, which helps the boy or girl
to feel safe and encouraged to learn, to fit in with others, and to cope
with the various stresses encountered in growing up. In other families
and schools, lack of basic economic resources for food, shelter, clothing,
and health care; chronic tensions between family members; or physical
or mental health problems of caretakers may provide stress, which
makes it far more difficult for the child with ADHD to cope and ade
quately develop. A classic study by child psychiatrist Michael Rutter
(Rutter and Quinton 1977) demonstrated that six factors within a family
correlated significantly with various psychiatric problems in children:
1) severe marital discord, 2) low social class, 3) large family size, 4) pater
nal criminality, 5) mental illness of the mother, and 6) foster placement.
He found that no one of these factors alone specifically impaired devel
opment, but each one added to the negative effect on the children.
The impact of adversity is often seen in clinical practice, but adver
sity at home or school is especially problematic for those children who
suffer from ADHD. Some children live with parents who are so preoc
cupied in their own struggles with finances, medical illness, chronic
marital conflict, depression, anxiety, addiction, and so forth that they
are unable to provide much consistent attention or support to their chil
dren, especially when a child has special needs beyond the needs of
most other children of the same age. Some mothers and fathers are
chronically engaged in intense conflicts with one another over their chil
dren, one harshly criticizing and punishing the child while the other
takes the opposing side, blindly defending the child against all criti
cism; both leave the child stressed and confused, caught in the paralyz
ing guilt of loyalty conflicts.
In some families with a child who has ADHD, parental conflict po
larizes over the issue of whether the child does or does not suffer from
impairments of ADHD. One parent may see treatment for ADHD as es
sential to the child’s future growth, whereas the other is steadfastly op
posed to such a diagnosis and to any accommodations or treatment for
ADHD. It is very difficult when one parent tells the child with ADHD,
“It’s really important for you to take your ADHD medication every
day,” while the other parent feels the medicine is likely to be harmful
and begs the child to avoid taking it.
In some other families, parents are consistently engaged in support
ing their child with ADHD. They encourage and support the child in his
or her schoolwork and in peer relationships; they keep in touch with the
child’s teachers and monitor the child’s homework on a daily basis.
They are realistic in recognizing areas in which the child needs extra
support or remedial tutoring, and they work hard to provide what is
needed, while also recognizing and encouraging the child’s strengths in
whatever academic or social domains they appear. Any child with
ADHD who has such support on a reasonably consistent basis is likely
to suffer much less frustration, stress, and shame compared with the
child with ADHD whose impairments are compounded by chronic
stress and lack of consistent support at home.
School experience can be a powerful source of stress or a resource of
support for the child with ADHD. Some teachers understand very well
that the student with ADHD may be suffering from dramatic inconsis
tency in academic performance or in classroom behavior not because of
willfulness or laziness but because that child, at that point in his or her
development, does not have adequate control. Faced with this ongoing
disappointment and frustration in their efforts to help that child while
also attending to the needs of their other students, some teachers are
quite patient, doing all they can to help such students.
Other teachers become chronically angry and confrontational with the
student who has ADHD, often shaming or punishing the student while
continually complaining to the child and his or her parents about the need
for improvement of these shortcomings, which the student may be unable
to control effectively. Encountering subtle indications or overt confronta
tions day after day from the teacher who is frequently disappointed, frus
trated, and annoyed with the student’s ADHD-related impairments can
seriously sabotage that child’s self-esteem as well as his or her motivation
for sustaining effort in school and hope for eventual success.
There are many types of environmental stress that can impact any
child or adult. Thus far, there have been few studies of how stressors
such as unemployment, change of residence, disruption of a close
friendship or marital relationship, excessive debt, incarceration, serious
illness, or death of a close friend or family member might exacerbate im
pairments of persons with ADHD. One study of adults with ADHD
found that those whose ADHD symptoms are more severe tend to also
experience a greater frequency of negative life events than do those with
less severe ADHD, regardless of whether they also have a comorbid
psychiatric disorder (Garcia et al. 2012). In some cases, the individual’s
ADHD-related impairments may have contributed substantially to the
negative life events (e.g., disruption of relationships, family conflict,
loss of employment). In other instances, it may be that individuals ex
perienced serious worsening of their ADHD because they were more se
verely deprived of adequate family security and support at critical
points in their growing up.
Summary
All individuals have difficulty with impairments characteristic of
ADHD sometimes, but that does not mean that everyone has ADHD.
The diagnosis is appropriately used only for those children, adoles
cents, or adults who persistently experience much more chronic and sig
nificant impairment in their executive functions than do most others of
the same age group. Persons with ADHD have these significant impair
ments in common. Nevertheless, there are many differences among
those who are appropriately diagnosed with ADHD.
This variety includes differences in severity of impairment, intensity
of hyperactivity and/or impulsiveness, age at onset, persistence or re
mission of symptoms, gender, underlying temperament, cognitive abil
ities, and environmental challenges and supports. The main point of
this chapter is that those with ADHD are not all alike in their strengths
or in their difficulties.
To understand and respond adequately to a person with ADHD, the
clinician needs to take into account the unique strengths and vulnera
bilities that emerge from that patient’s life history and current life situ
ation. In Chapter 4, I discuss how ADHD impacts persons at different
ages and stages of development, and in Chapter 7, I describe the ways in
which ADHD is often complicated by additional learning and/or psy
chiatric or medical disorders.
4
Ways ADHD Can
Impair Functioning at
Various Age Levels
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
(ADHD) is now understood as essentially developmental impairment
of the brain’s self-management system, its executive functions. The
brain structures that support executive functions are not fully devel
oped in early childhood; they are among the slowest developing as
pects of the human brain. Early foundations for executive functions
begin to emerge quite gradually beginning in the second year of life, but
these complex systems for self-management do not fully mature until
the late teen years, early 20s, or later.
The model of executive functions introduced in Chapter 2, “A New
Model of ADHD,” includes six clusters (Brown 2001):
1. Activation: Organizing, prioritizing, and activating to work

2. Focus: Focusing, sustaining, and shifting attention to tasks
3. Effort: Regulating alertness, sustaining effort, and adjusting pro
cessing speed
4. Emotion: Managing frustration and modulating emotions
5. Memory: Utilizing working memory and accessing recall
6. Action: Monitoring and self-regulating action
45
Each of these clusters is a grouping of a variety of cognitive functions

that work together to allow a person to take on and deploy knowledge
and skills to accomplish a variety of different tasks in daily life. For very
young children, those functions are quite basic, but gradually over the
years of childhood and adolescence, executive functions develop so the
emerging individual learns to manage more complex tasks and to func
tion more independently. As the brain develops, if caretakers provide
ample opportunities and encouragement, the typical child gradually
learns to do a wider variety of tasks without constantly needing some
one else—a parent, older sibling, or other adult—to provide step-by
step directions on what needs to be done, how to accomplish the task,
and when to do that specific task.
There is a wide range of “normal” in development of executive func
tions. We know that some young children learn earlier than others such
tasks as how to dress themselves without excessive delay, to tolerate
frustration without throwing a tantrum when they do not immediately
get what they want, to plan and manage their toilet functions so they do
not wet or soil themselves before they get to the bathroom, to take turns
with others without pushing or pouting, and to look and move carefully
to safely cross a street without an adult to hold their hand. Almost all
children eventually master such tasks in early childhood.
Although the range of normal for such development is wide, there is a
certain point at which most adults would agree that if a child has not man
aged particular tasks by a given age, there is something wrong. The child is
not meeting usual expectations for development. If the child is intellectu
ally or neurologically disabled, suffering global impairments in multiple
domains of functioning, such delays are understandable. But if a child hav
ing chronic difficulties in self-management is otherwise adequately devel
oping, then the question may be raised as to whether that child is possibly
suffering from the syndrome of impairments known as ADHD.
For decades, it was assumed that any child who has ADHD would
show at least some significant signs of impairment in self-management
skills by age 7 years. In DSM-5 (American Psychiatric Association 2013),
that age was raised to 12 years, the rationale being that any child devel
oping ADHD will show some symptoms of such impairment before en
tering the teen years. In many, perhaps most, cases, vulnerability to
ADHD impairments does begin to show up before adolescence, al
though it may not always be noticed by parents and teachers at the time.
However, that is not always the case. Some individuals fully follow ex
pected patterns of development of executive functions until they are
more fully challenged by the greater demands for self-management that
do not fully emerge until mid-adolescence, early adulthood, or later.
Ways ADHD Can Impair Functioning at Various Age Levels 47
When considering impairment, it is always necessary to ask the ques

tion “Impairment for what tasks and with what stressors or supports?”
For example, it is not uncommon for very bright students to earn honor
roll grades in elementary school while they are in one classroom most of
the day with one teacher who is able to provide considerable structure
and consistency. Those same students may begin to have more difficulty
when they move into middle school or high school, where they are re
quired to move from one teacher and classroom to another throughout
the day, adjusting to the differing structure and demands of each one. In
addition, they are now expected to take increasing responsibility for
monitoring what assignments are due; allocating sufficient time to com
plete the work by given deadlines; and balancing the often conflicting
demands of multiple assignments, quizzes, or tests with a variety of
competing academic, athletic, family, and social interests and commit
ments.
Some students with ADHD manage these demands in high school
reasonably well so long as they are living at home with parents who are
providing consistent scaffolding—enforcing requirements for reason
able sleep and eating patterns and protected time for homework and
study and ensuring avoidance of alcohol and drug use, abstinence from
excessive screen time, adequate preparation for tests, and attention to
deadlines for major assignments. However, those same students, how
ever bright, may struggle and fail to perform adequately when they
move away from home to attend college without the protective scaffold
ing their parents were providing. Under the stress of increasing de
mands for self-management with reduced support, many students with
ADHD struggle considerably, and some are unable to continue.
Although there may be considerable variability in what is expected
from a child of a particular age from one family or community to an
other, some expectations are generally consistent for broadly defined
age groups. The following sections offer examples of some of the chal
lenges that individuals are usually expected to meet at various age lev
els, challenges that involve significant use of executive functions.
Following each item is a brief description of how persons with ADHD
often are impaired in meeting such challenges consistently because of
their ADHD-related impairments of executive functions.
The purpose of these examples is to illustrate how the six clusters of
executive functions impaired in ADHD take on different forms depend
ing on the age of the affected person and the developmental challenges
associated with that particular age group. Impairment is associated
with the specific challenges of daily life faced by a given person at a spe
cific time of life.
Impairment is present when the person is not able to adequately per

form adaptive life skills usually expected of most individuals in that in
dividual’s particular age group and setting. Each of these adaptive skills
requires exercise of one or more executive functions, and each is mas
tered only gradually. Individuals do not master each of these skills fully
during the specified age period, but most are able to develop some level
of mastery during that age period. With each adaptive skill, there is a
brief description of how ADHD-related executive function impairments
may impact that function.
Some Adaptive Skills Usually

Expected of Preschool Children
• Behave carefully, avoiding significant risks. Often, preschool chil

dren with ADHD do not behave as carefully as most other children of
similar age. Long after most of their peers have learned to be careful
around hot stoves and sharp knives and not to run into the street to
chase a ball and not to jump from high places, for example, those with
ADHD are likely to take such risks because their impairments in
working memory prevent them from recalling relevant parental warn
ings about such things in time to prevent impulsive actions that may
result in getting hurt (Dalsgaard et al. 2015a; Schwebel et al. 2002).
• Get dressed without excessive assistance. Often preschool children
with ADHD continue to need step-by-step adult supervision to do ba
sic daily tasks such as getting themselves dressed in the morning. Such
tasks tend to take much longer than for most of their age-mates because
children with ADHD tend to get sidetracked much more frequently,
easily becoming involved in just dawdling or playing with toys while
completely forgetting what they started out to do. They have trouble
keeping immediate goals in mind; they are easily distracted.
• Cooperate in shared play with others. When preschool children
with ADHD participate in free play or organized activities with other
children, they often ignore what others are doing and focus only on
what they want to do. They may be reluctant to share toys or to take
turns, tending to be more impatient with waiting than most others.
Once involved in an activity, they may stubbornly refuse to stop an
activity so they can transition to something else that needs to be done.
They have trouble shifting focus.
• Modulate extreme emotional reactions. More than most of their
peers, preschoolers with ADHD tend to have extreme emotional re
actions when they are disappointed, frustrated, angry, or frightened.

If they are required to wait for something they want, if they lose in a
game, or if they are told “No” to something they want to do, they
tend to lose perspective and get flooded with emotion. Even for mi
nor frustrations, they are likely to scream or lash out in anger or to
persist in demanding what they want louder or much longer than
many others of the same age (Sobanski et al. 2010).
As each child grows older, adaptive skills such as those listed above
are expected to become stronger and to be more consistently demon
strated in a wider range of activities and settings without constant need
for adult step-by-step reminders or intervention. Being careful may ex
pand to riding a bike carefully in the street; doing tasks without need for
excessive supervision may apply to homework or household chores. As
the child reaches elementary school, expectations gradually develop for
additional adaptive skills.
Some Additional Adaptive Skills

Usually Expected of Elementary
School Children
• Demonstrate motivation to learn and use age-appropriate aca

demic skills. Motivation to learn involves keeping in mind potential
rewards to be gained by learning and using academic skills. These
potential rewards may be praise from parents and teachers, master
ing skills that older kids already have, or getting good grades on a re
port card. Often, children with ADHD have difficulty keeping such
longer-term goals in mind; they tend to be too focused on immediate
interests and satisfactions, especially if the environment does not
provide the necessary encouragement on an ongoing basis (Luman et
al. 2005).
• Sustain focus and effort on assigned tasks, even when the task is
not especially interesting. Although children with ADHD can be
very focused and work very hard on tasks that especially appeal to
them, they tend to lose interest quickly and become bored with as
signed tasks that they do not find interesting. They tend to become
distracted easily and to redirect their attention to other stimuli as
they search for more enjoyable pursuits. Sometimes they lose focus
because they have not attended carefully to directions given or are
not able to monitor themselves when off task (Brown 2005a).
• Organize and keep track of belongings and materials needed for

school and activities. Parents and teachers often complain that chil
dren with ADHD tend to lose track of their belongings and needed
materials; they may complete a homework assignment and then lose
it in their backpack or forget to hand it in to the teacher. They fre
quently forget to bring home or return permission slips needed for
school activities. This reflects ADHD-related problems with working
memory, difficulties with keeping more than one thing in mind at a
time. Unless reminded by someone, the child with ADHD packing
his backpack at the end of the school day is likely to forget what will
be needed that night for homework while preparing to get on the
school bus or to walk home.
• Develop and maintain friendships and activities with some others
of comparable age. Developing and maintaining friendships re
quires some sensitivity to the needs and feelings of the friend as well
as finding ways to meet one’s own needs in interaction. Many chil
dren develop these skills while engaged in unstructured play or in
organized activities where they play a sport with a team, take group
lessons in dance, or participate in scouts or other clubs. Although
some children with ADHD do quite well in such interactions, many
struggle with excessive inattention for the shared tasks or in over
reacting to criticism or teasing. Longitudinal studies have shown that
as a group, children with ADHD have markedly elevated rates of re
jection by their peers (Hoza et al. 2005; Pelham and Bender 1982).
As the child moves gradually into adolescence, he or she is expected

to continue to expand and refine development of adaptive skills such
as those listed above for younger students. Many teenagers are still
working on learning to modulate their excessive emotional reactions to
frustrations. Many struggle to demonstrate motivation for learning ac
ademic skills and to sustain adequate focus and effort for assigned tasks
that do not interest them. For most adolescents with ADHD, these strug
gles are more intense, persistent, and pervasive than for most of their
age-mates.
Adolescents are reacting to emerging or awaited bodily changes of
puberty and also tend to feel pressures to become increasingly indepen
dent of their parents. They also encounter increasing demands on their
time and energy from school, extracurricular activities, social media,
friends, and family. In the midst of all this, adolescents encounter esca
lating expectations to develop even more adaptive skills, as outlined in
the following section.

Usually Expected of Adolescents
• Sustain motivation to refine academic skills for adequate oral ex
pression, reading comprehension, math concepts and calculations,
written expression, and basic cultural knowledge. To prepare for
adequate functioning as adults, adolescents are expected to develop
at least high school levels of skills for oral communication, reading
comprehension, math, and expressing themselves in writing, as well
as basic cultural knowledge of history, government, and other sub
jects. Although many students with ADHD successfully pursue col
lege and graduate-level degrees, a sizable percentage have difficulties
due to their ADHD-related impairments with executive functions,
which may cause them to drop out of high school without earning a
diploma or discourage them from pursuing postsecondary schooling
(Pingault et al. 2011).They may become caught up in persistent hope
lessness and apathy about themselves and their potential success in
life (Torrente et al. 2011).
• Keep track of assignments for multiple classes and prioritize tasks
and activities, allocating and using sufficient time to study and to
complete homework assignments on time. Many adolescents with
ADHD struggle daily to prioritize tasks and manage their multiple
commitments. Often, they unrealistically trust themselves to keep all
the important tasks in mind, forgetting that working memory im
pairment is a primary aspect of ADHD. Many also are unrealistic in
estimating time needed for tasks and tend to wait until the last min
ute to start assignments, often leaving themselves insufficient time to
do a good job.
• Maintain a routine for adequate sleep, nutrition, and exercise. Ad
olescents as a group tend to have difficulty maintaining adequate
sleep and nutrition. Those with ADHD often have much more diffi
culty in quieting their minds to get to sleep at a reasonable time, and
they struggle daily with awakening on time, regardless of how much
sleep they have had (Cortese et al. 2009). Some enjoy exercise; others
avoid it. Many with ADHD do not maintain adequate nutrition, es
pecially if medications they take for ADHD persist in diminishing
their appetite. If they move out of their parental home to attend col
lege or get a job, they often have considerable difficulty in maintain
ing a stable daily regimen that promotes adequate sleep, nutrition,
and exercise.
• Avoid excessively risky or dangerous behaviors, including use of

illicit drugs or alcohol and reckless driving. Prevalence of substance
use disorders among adolescents with ADHD is almost double the
rate among those without ADHD (Lee et al. 2011); this age group also
has elevated rates of motor vehicle accidents (Barkley et al. 1996,
2002; Thompson et al. 2007). It is extremely difficult for parents to
monitor and control these behaviors in their adolescent sons and
daughters, and peer pressures may be strong.
• Learn to understand, enjoy, and manage sexual interests while
avoiding excessive risks. Sexual interests and relationships are very
important for most adolescents; these rarely are discussed by ado
lescents with their parents or other adults. Adolescents with ADHD
often struggle with complications of finding and working out rela
tionships with potential partners and also have difficulty managing
their own emotional reactions to the ups and downs of dating rela
tionships. Many also are impulsive in sexual relationships, especially
when they are drinking or taking drugs, and tend to take excessive
risks with exploitative relationships, sexually transmitted disease, or
unwanted pregnancy (Barkley et al. 2008).
• Learn to drive a motor vehicle, qualify for a license, and drive
safely. Many adolescents look forward to getting a driver’s license so
they can have increased freedom to get themselves around indepen
dently without their parents; they also view it as a status symbol.
Some adolescents with ADHD are very careful and competent driv
ers. However, as a group, teens with ADHD tend to have more motor
vehicle violations and more motor vehicle accidents than do others of
the same age. Their ADHD-related difficulties with impulsive re
sponding, excessive distractibility, and inadequate modulation of
frustration can put them at increased risk when in the driver’s seat
(Thompson et al. 2007; Vaa 2014).
• Develop and implement a realistic plan for life after high school.
The transition from high school to postsecondary education is for
many teenagers the most challenging transition they have yet en
countered. As high school concludes, many, although not all, teenag
ers struggle to select and gain admission to a school to pursue more
education, which may involve moving away from home to live inde
pendently, without daily contact with their parents and separation
from most of the friends who have been their community for many
years. For most, this is a welcome transition that works out well.
However, for many with ADHD, persisting difficulties with self
management for productive work, allocating priorities for studies
and socializing, avoiding excessive alcohol and drug use, and regu
lating daily routines undermine their success and may disrupt their
schooling and limit their career.
For some individuals who experience ADHD during childhood
and early adolescence, their ADHD-related impairments of executive
function gradually diminish as they reach their late teens and early
20s. Reasons for this are described in Chapter 3, “Differences Among
Persons With ADHD.” Those fortunate persons who experience con
siderable remission of their ADHD impairments may deal with the
additional expectations of young adulthood as effectively as most of
their peers (Sayal et al. 2015 ). For those whose ADHD impairments
persist, either for lack of diagnosis and adequate treatment or be
cause attempted treatments have been ineffective, the increased ex
pectations encountered during early adulthood may be extremely
challenging, placing them in situations where they are not able to
keep up with the levels of accomplishment attained by most of their
peers. For those affected, this may lead to much disappointment and
frustration, particularly if they become alienated from their more
successful peers and remain more obviously dependent on their par
ents for a variety of financial and practical supports than do most of
their age-mates. Yet even for those whose ADHD-related impair
ments become less severe as they get older, the following expecta
tions of young adulthood can be quite challenging.

Usually Expected of Young Adults
• Complete appropriate education and training to prepare ade

quately for a career. Young adults are usually expected to obtain ed
ucation and/or training that will prepare them to earn an adequate
living. For those who pursue skilled professions, this may require
many years of college and graduate-level education followed by su
pervised postgraduate training. Others enter fields for which train
ing is more technical, requiring apprenticeship; still others proceed
directly from high school to learn their work skills on the job. Among
those whose ADHD-related impairments persist into early adult
hood, especially if they remain untreated, the demands of postsec
ondary education may become overwhelming, causing them to take
longer than most peers to complete their degree or training program.
In some instances, they are unsuccessful and abandon their original
plans, seeking whatever other employment they find available. Most
studies indicate that, as a group, those with persisting ADHD have

lower levels of academic achievement, complete fewer years of post
secondary education, and have a lower percentage of completing a col
lege degree than matched control subjects without ADHD (Biederman
et al. 2006; Frazier et al. 2007; Kuriyan et al. 2013; Stavro et al. 2007).
• Find and maintain employment to earn adequate income. Transi
tioning from high school or postsecondary schooling to employment
is difficult for almost everyone, but those young adults who have
persisting ADHD-related impairments tend to have considerable dif
ficulty in finding and keeping a job. As job seekers, many with
ADHD struggle intensely with inevitable frustrations in researching
potential job openings, filing numerous applications while receiving
few encouraging responses, and performing well in stressful inter
views. Once hired, rookie employees with ADHD often find it espe
cially difficult to learn quickly and remember new required skill sets,
to accommodate to supervisors who may not be supportive, to meet
expectations for consistent promptness and minimal absences, and to
fit themselves into the social system at work as they begin employ
ment at a place where the rules may be very different from what they
were in school. Some with ADHD negotiate these transitions quite
successfully, but others suffer with long periods of unemployment or
find it necessary to accept a job with much smaller rewards and fewer
opportunities for advancement than they hoped for or expected. One
of the few controlled studies of employment problems compared
adults with ADHD with matched control subjects in the same com
munity. Results indicated that those with ADHD reported signifi
cantly more difficulties in their work history than did those in a
community sample. These difficulties included having more fre
quent conflicts with others on the job, having more often quit their
job out of boredom, having been disciplined by their supervisor more
frequently, and having been fired more often (Barkley et al. 2008).
• Manage money, pay bills, and avoid excessive debt. Young adults
are expected to develop not only the ability to earn money but also
the ability to manage the money they earn. This is quite challenging
for many adults with ADHD, given their tendency to focus exces
sively on the present moment, often acting impulsively and giving
less attention to future consequences. One study that compared
adults with ADHD with community control subjects found that those
with ADHD reported significantly more difficulty in saving money
and more buying on impulse. They had missed their rent payment
more often, had experienced their utilities being turned off because of
nonpayment, had had a vehicle repossessed, had declared bank

ruptcy, or had not saved for retirement (Barkley et al. 2008).
• Develop and sustain relationships with friends and possibly a part
ner. In recent decades in the United States, we have seen significant
changes in patterns of dating and marriage. Fewer young adults are
marrying in their early 20s; the majority of first marriages now occur in
mid to late 20s or beyond, while an increasing number of adults remain
single (Centers for Disease Control and Prevention 2015). At the same
time, there is a reported increase in the number of couples who live to
gether during young adulthood, sometimes as a prelude to a committed
relationship and sometimes simply as a convenient temporary arrange
ment (Copen et al. 2013). Among young adults with persisting ADHD
compared with community control subjects, limited studies indicate no
significant differences in the percentages of young adults currently dat
ing someone, in the length of their dating relationships, or in the number
of persons dated over the previous 5 years (Barkley et al. 2008). How
ever, in one such study, there was a significant difference between
these two groups in their reported level of satisfaction with their dat
ing relationships. Reports indicating fair to poor quality in dating re
lationships were four to five times more frequent among young
adults with ADHD than in community control subjects (Barkley et al.
2008). There are insufficient empirical data, at present, to explain this
difference. However, clinical data suggest that many young adults
with ADHD struggle with chronic difficulties in negotiating mutu
ally satisfactory resolutions to the misunderstandings and conflicts
that typically arise in the early stages of more intimate relationships.
It is not easy to draw a clear boundary between young adulthood

and what might be called simply adulthood. Some individuals in their
mid to late 20s have completed their education, are employed full-time,
have their own home, fully support themselves financially, have a stable
relationship with a partner, and may be parenting one or more children.
Others of the same age are still years away from such a situation, either
because they are engaged in protracted professional education and
training that does not yet provide much financial support or because
they have not been successful in finding adequate employment to en
able them to support themselves consistently, possibly because of bad
luck or the impairments of executive function associated with ADHD.
However, at some point, some additional adaptive skills such as the fol
lowing are usually expected from most adults, although there are many
who are not able or choose not to achieve or sustain these tasks.

Usually Expected of Adults
• Sustain employment to provide ongoing support for oneself and

any dependents. Adults generally are expected to sustain employ
ment that will allow them to pay living expenses for themselves and
any dependents, without relying on parents or others to provide sup
port unless there are unusual circumstances of disability or misfor
tune. Unless the individual has inherited extraordinary financial
resources, this requires steady employment, which depends on many
factors, only some of which are under the control of the individual
worker. One study (Barkley and Murphy 2010) compared employer
ratings of work performance of adults with persisting ADHD with
adult workers in a group of community control subjects who did not
have ADHD. Without being informed about which workers had
ADHD, employers rated workers with ADHD as more impaired in
their work performance, pursuing fewer educational opportunities
at work, being less punctual, showing poorer time management, and
doing less well in managing daily responsibilities than workers in the
community control group. Interestingly, these employer ratings were
quite consistent with self-ratings by workers in each group who were
asked to describe their own work performance. They also were con
sistent with the findings that those adults with ADHD reported hav
ing had more different jobs since high school and shorter lengths of
stay on previous jobs than reported by community control subjects. It
is important to keep in mind, however, that these are group data.
Among those with ADHD, there are many who perform extremely
well at their jobs, but that is not the overall trend for the group.
• Develop and sustain mutually satisfying relationships with
friends and/or a partner. Most, although not all, adults tend to seek
mutually satisfying relationships with some friends; many also are
motivated to develop a more intimate and lasting relationship with a
chosen partner. For some, there are many different friends, perhaps a
small group that spends considerable time socializing together once
or twice almost every week. For others, friendships are more individ
ualized, usually maintained on a one-to-one basis. Still others narrow
their social contacts to focus on one very close friend who may or
may not become a longer-term partner, a friend with benefits, or per
haps a marriage partner. Among those with ADHD, some have very
stable and satisfying social relationships, but for others these rela
tionships are frequently and painfully disrupted or ended; for some,

there is a succession of new acquaintances, friends, or dating part
ners. For those individuals with persisting ADHD who do marry, re
ports of marital satisfaction from both the partner with ADHD and
the mate without ADHD tend, in group data, to be much lower than
such reports from matched samples of control subjects without
ADHD. Such relationships may be destabilized by ADHD-related
problems of excessive forgetfulness, chronic inattention to the needs
of the partner, and/or lack of dependability in keeping a commit
ment (Eakin et al. 2004). Emotional dynamics of such relationships
are discussed more fully in Chapter 9, “Emotional Dynamics in Indi
viduals, Couples, and Families Coping With ADHD.”
• Establish an adequate home for oneself and any partner or depen
dents. Establishing a home does not necessarily mean buying a
house or condominium; nor does it necessarily refer to a place where
one will live for a long time. Most adults seek for themselves and are
expected to develop for themselves living quarters that they regard
as their home, not simply a place to live temporarily while they con
tinue to consider the home of their parents to be their only real home.
Regardless of whether the space for this home is rented, bought with
a mortgage, or purchased outright, as they settle into their own
home, adults usually begin to make or acquire some furnishings and
decorations that help to personalize their home and to spend time
and effort in cleaning and improving it, even if their stay in that place
may be rather short. In a study comparing adults with persisting
ADHD with community control subjects, those with ADHD reported
significantly more difficulties in managing home-related finances,
such as missing rent payments, missing loan payments, and missing
utility payments (Barkley et al. 2008). These difficulties are likely due
to ADHD-related impairments of executive function such as plan
ning, prioritizing, and monitoring one’s actions.
• Parent one or more children, when desired and ready and with ad
equate resources, providing emotional, financial, and practical
support for their education and development. Not all adults want to
become parents, but many look forward to having a child or children
and caring for them as a very important part of their life. What is ex
pected of adults who choose to become parents is that they will be re
sponsible for providing adequate protection, love, and care as well as
sufficient financial and practical support for any children they give
birth to or adopt until the children are old enough and able to take
care of themselves. Many parents who have ADHD provide consis
tently excellent care for their children, but some episodically or
chronically struggle to provide adequate parenting support for their

children. They may be too inconsistent in providing structures for en
couraging appropriate behaviors and discouraging inappropriate
behaviors. One complicating factor, in addition to the ADHD-related
impairments of the parents, may be that because of the high herita
bility of ADHD, many parents with ADHD have offspring who also
have ADHD. These children are likely to be more challenging to raise
and care for. In parenting couples where one or both have ADHD, es
timates are that 43%–56% of the children have ADHD. Providing ad
equate parental care to assist children who have ADHD with the
daily tasks of managing behavior, meeting expectations in school,
coping with peer interactions, sustaining good health care, and meet
ing other demands of family life can be very challenging for any par
ents; it is likely to be considerably more difficult for parents who
themselves continue to grapple with ADHD. For example, many
children with ADHD need their parents to be much more involved in
collaborating with teachers and other school staff to monitor assign
ments and achievement levels. These children may also need their
parents to advocate for them with school officials to make certain that
they get adequate educational support and any needed accommoda
tions or special education services. Children with ADHD also are
likely to have special needs for diagnosis and supportive treatment,
which probably involves regular consultations with physicians, psy
chologists, or other mental health professionals. Many also need to
take prescribed medications for their ADHD and need parents to
monitor their medications, refill the medications as needed, and keep
health care providers aware of any emerging difficulties for which
adjustments or changes in treatment and support may be needed.
These added responsibilities can be quite difficult for any parents;
they can be overwhelming for some parents with continuing ADHD
despite their wish to do well.
• Manage health care and insurance for oneself and any dependents.
Whether an adult has children to care for or not, another important
adaptive skill is taking care of one’s own health with good dietary prac
tices, regular preventive health care, and adequate dental care. This in
volves not only attending to health problems conscientiously when they
arise but also keeping track of when one ought to make an appointment
to see a health care provider for a checkup, keeping needed prescriptions
refilled, taking medications as needed, and so forth. To support these
health care services and treatments, for oneself and one’s family, rou
tines need to be established and maintained, insurance coverage needs
to be arranged and maintained, forms need to be completed, and pay
ments need to be made. For those with persisting ADHD, caring for their
own health also involves obtaining and sustaining appropriate medical
and, if needed, mental health treatment for their ADHD impairments
and related disorders. Population studies have shown that those with
persisting ADHD have increased risk of premature death, usually due to
accidents (Dalsgaard et al. 2015b). One population study found sig
nificantly elevated risk of suicide or attempted suicide among per
sons with ADHD (Ljung et al. 2014).
• Contribute emotional support and necessary care to aging parents
and extended family. In addition to coping with the adaptive respon
sibilities described above, as adults get older, other concerns and
challenges often arise from aging parents and possibly other ex
tended family members—grandparents, siblings, aunts, uncles,
cousins, or others—who may need help with managing emerging
health problems or other life stresses. Loyalties to these family mem
bers, particularly as they enter their later years, often cause adults to
struggle with multiple demands and desires to provide emotional,
practical, and/or financial support, small or large, short term or lon
ger term. This involves time for staying in touch and helping out in
addition to the ongoing responsibilities or pressures from their im
mediate family, work, and other interests.
These responsibilities to parents and extended family are some
times quite limited and may be shared by numerous other family
members. Sometimes, however, such responsibilities may be ex
tremely burdensome and long-lasting in ways that would be over
whelming for any adult. For adults with persisting ADHD, managing
such multiple tasks and expectations may be extremely difficult, es
pecially when they arise as the adult himself or herself is dealing with
the various demands of daily life and also approaching a time when
more detailed planning for his or her own aging and retirement may
also need increasing consideration.
At present, there are few systematic studies of how adults with

ADHD fare in midlife and beyond. One population-based study of
adults in Australia ages 47–54 years (Das et al. 2012) found that those
with ADHD were more likely to be unemployed in midlife, more likely
to be suffering from financial problems, more likely to be separated or
divorced, and more likely to report depressive symptoms than those
without ADHD. There was no significant difference between men and
women on these midlife measures.
Looking at a sample of adults with ADHD at an average age of 68 years,
researchers in the Netherlands found that those with ADHD tended to
have lower income, had three times greater odds of being divorced or
never married, had a more limited network of social contacts, and re
ported higher levels of emotional loneliness than a comparison group of
adults of comparable age without ADHD (Michielsen et al. 2015a, 2015b).
It should be noted, however, that these are group data, and not all partic
ipants with ADHD experienced the reported impairments.
Summary
Executive functions depend upon an infrastructure composed of the
slowest developing structures of the human brain. Neuroscience data
demonstrate that although primordial foundations of those functions
begin to emerge in preschool years, the brain’s management system
does not approach maturity until an individual’s late teen years, early
twenties, or even later. In this chapter, I describe specific skills and adap
tive behaviors usually expected from individuals at various stages of
development from preschool years to adulthood and the ways in which
individuals with ADHD often struggle with those challenges over the
course of development.
The chapter does not include all the additional challenges often faced
by many in the general population as well as individuals with ADHD.
Examples include job losses, disruptive relationships in marriages and
parenting, persisting poverty, severe and chronic physical or mental ill
ness in key family members, untimely deaths of friends or family mem
bers, and any of the wide variety of misfortunes and bad luck that may
occur throughout life. What often is amazing is the way that many chil
dren, adolescents, and adults—with and without ADHD—often cope
extremely well with such misfortunes. However, among those with
ADHD, such additional stressors can become overwhelming.
5
How ADHD Impacts
“Brain Googling”
for Motivations
IN CHAPTER 1, I DESCRIBE THE CENTRAL MYSTERY

of attention-deficit/hyperactivity disorder (ADHD):
Although they have considerable chronic difficulty in getting organized

and getting started on many tasks, focusing their attention, sustaining
their efforts, and utilizing their short-term working memory, all of those
diagnosed with ADHD tend to have at least a few specific activities or
tasks for which they have no difficulty in exercising these very same
functions in a normal or even extraordinary way.
This puzzling inconsistency, this ability to exercise executive func

tions very well in certain specific situations or for some specific tasks but
not others, makes it appear that ADHD is a problem with willpower.
Many people who see these differences in persons with ADHD from one
situation to another, and many with ADHD themselves, assume that if
someone is capable of mobilizing his abilities for one task or situation, he
ought to be able to do it in other situations as well if he really wants to.
This willpower assumption is based on two fundamental misunder
standings of how the human brain works. This assumption ignores the
complex and powerful role of unconscious emotions in the brain’s pro
61
cesses of motivation, and it does not recognize the critical importance of

working memory for prioritizing tasks moment by moment. There are
several similarities between a Google search for information on a given
topic and the process of the human brain in shaping motivations. Al
though there are important parallels, important differences also exist.
Similarities and Differences Between

Google and the Human Brain
Both Google searches and the human brain perform the following:
• Process massive amounts of continually updated visual and verbal

information
• Form linkages between bits of information, both visual images and
verbal content
• Select and prioritize relevant information to respond to a query
within milliseconds
Google has collected and continues to update and index more than
100 million gigabytes of visual images and verbal content. When pre
sented with a query, Google rapidly searches its index to find relevant
content and seeks out additional information linked to that content.
Google then prioritizes that selected content according to its apparent de
gree of relevance to the immediate query and the frequency with which
each piece of content has been utilized in previous similar searches by
others. Google presents the results of all this searching and prioritizing
within seconds or milliseconds.
At present, there is no way to quantify how many units of visual and
verbal information are stored in the human brain, nor is there any measure
to quantify the rate and ways in which this information expands in the
brain from infancy across the years of an individual’s life span. Neverthe
less, most people would agree that any given individual’s unique store of
images and verbal content rapidly expands to massive proportions over
the course of life experiences. The unique differences between one person’s
information base and another’s and the expression of these differences are
major factors in what makes us puzzling and interesting to one another.
The primary difference between Google searches and any given in
dividual’s motivations, beyond the obvious differences in the size of the
information database, is the process by which relevance and prioritizing
of information are determined. Google prioritizes based on the rele
vance of manifest content, which words and synonyms match, and on
How ADHD Impacts “Brain Googling” for Motivations 63
the frequency of demand in similar searches by others. In contrast, the

primary basis on which humans prioritize information is the emotion
associated with conscious and unconscious memories activated by the
individual’s thoughts and perceptions at any given moment.
Emotions Prioritize Motivations

in the Brain
In 1996, neuroscientist Joseph LeDoux published The Emotional Brain, a
book highlighting the central importance of emotion in the brain’s cogni
tive functioning. He emphasized that emotions—mostly unconscious emo
tions—are powerful and critically important motivators of human thought
and actions (LeDoux 1996). This understanding of the essential role of
emotion in all aspects of human motivation and behavior has not yet been
adequately integrated into current thinking about ADHD (Brown 2014).
Emotions, both positive and negative, play a critical role in executive
functions of the brain: initiating and prioritizing tasks, sustaining or
shifting interest and effort, holding thoughts in active memory, and
choosing to engage in or avoid a task or situation. As was observed by
neuroscientist Kenneth Dodge (1991), “All information processing is
emotional....Emotion is the energy level that drives, organizes, ampli
fies and attenuates cognitive activity” (p. 159).
Whereas Google responds to queries typed into the search engine,
the human brain responds to its own constant flow of perceptions and
thoughts according to valences and intensity of emotions attached to as
sociated memories. Each person’s brain establishes the relevance and
level of priority of whatever is being perceived or thought about on the
basis of that individual’s personal history of learning from life experi
ences consciously and unconsciously remembered in that moment. Re
called experiences are colored by emotions of various types and
intensities. The type and intensity of associated emotion, as recalled,
provide the basis on which the brain establishes personal priorities to
activate interest and engagement or disinterest and possible avoidance
in that moment (Pessoa 2013).
The Amygdala as an Important Hub

for Developing Priorities
One important hub for the brain’s personal searches is the network of
neural connections between the amygdala and various other neural net
works of the brain. The amygdala consists of a pair of relatively small

structures located deep in the brain near the meeting point of a line
drawn from between the eyes to the back of head and a line drawn from
one ear to the other. For many years, most researchers thought of the hu
man amygdala as serving only to alert the brain to possible dangers. It is
now well established that the amygdala also links to visual and audi
tory cues for multiple emotions, including pleasure and potential re
wards. It rapidly screens incoming stimuli, draws on unconscious
memories, and alerts the brain to potentially positive and rewarding
stimuli as much as to potential dangers (Vullumier 2009). It also plays a
particularly important role in social interactions (Buchanan et al. 2009).
The amygdala is one of the most richly connected areas of the brain.
It has more than a thousand connections to various other areas through
out the brain (Petrovich et al. 2001). Through these connections, it re
ceives information from all sensory systems of the body (e.g., sight,
hearing, touch, smell) as well as from the higher-level management ar
eas of the brain in the cortex. Its rich network of connections also allows
the amygdala to send out notifications of interest or warnings of poten
tial danger to other centers throughout the brain.
Each bit of information coming from any part of the brain—each
sight, each sound, each image, each thought, each imagining—is
screened automatically within milliseconds by the amygdala for possi
ble danger or possible payoff or reward. Much of what is screened is
composed of aspects of the person’s expected routine, which raise no
signal of immediate possible risk or likely payoff. But ambiguous in
coming data and cues related to previous experiences of pleasure or fear
quickly connect with emotion-laden memories of previous experiences
stored in other brain centers; those data can activate immediate inter
est—positive, negative, or both—which causes the amygdala to in
stantly alert other relevant areas of the brain.
Unconscious Prioritizing
by Emotions
Many people think of emotions as involving only conscious feelings,
limited to sensations of sadness, anger, pleasure, worry, and so on, that a
person is fully aware of and generally able to identify. Neuroscience has
shown that conscious feelings are only a tiny part of the rich and varie
gated range of emotions that operates within each person to motivate
executive functions. Neuroscientist Joaquin Fuster (2003) emphasized,
“Whereas we may be fully conscious of a retrieved memory—sometimes
painfully so—the vast majority of memories that we retrieve remain un

conscious” (p. 138).
Unconscious here is not the old psychoanalytic concept of repression.
Rather, it is the more modern sense of unconscious as automaticity. This
term refers to operations that occur so extremely rapidly within the
brain that there is no opportunity for conscious deliberation; they oper
ate automatically on the basis of ultrarapid communications within the
networks of the brain using memories from past experiences and per
ceptual data from the current context of the individual (Bargh 2005).
Often, these unconscious emotions conflict and cause us to act in
ways that are quite inconsistent with our recognized conscious inten
tions. An unrecognized undercurrent of conflicting emotions is often in
volved in our failure to do tasks that we believe we want to do or in our
directly or indirectly engaging in actions that we consciously believe we
do not want to do.
Sometimes a person thinks of a particular task as quite important,
honestly believing that he wants to give it immediate attention and sus
tained effort, yet he does not act accordingly. He may continue to pro
crastinate, busying himself with work on other tasks that are not as
urgent or repeatedly interrupting work on the seemingly important
task, making little actual progress. Or he may actively seek out distrac
tions by initiating contact with friends, surfing the Internet, getting
high, or going to sleep. Such contradictions make sense only when we
realize that emotions that guide our motivations often are not fully con
scious and are often conflicting. We may be powerfully influenced by
emotions that we do not even know we have.
LeDoux (1996) argued:
Many of the things we do, including the appraisal of the emotional sig
nificance of events in our lives and the expression of emotional behav
iors in response to those appraisals, do not depend on consciousness, or
even on processes that we necessarily have conscious access to. (p. 65)
Much of emotional processing goes on outside our awareness, and,

as the work of Freud and other psychoanalysts has demonstrated and
described, the less conscious emotions are often subtle, contradictory,
complex, and powerful. As neuroscientist Antonio Damasio (2003)
pointed out, unconscious influences of emotions can powerfully shape
and modify our executive functions in ways we cannot recognize:
[T]he emotional signal can operate entirely under the radar of conscious
ness. It can produce alterations in working memory, attention and reason
ing so that the decision-making process is biased toward selecting the action most
likely to lead to the best possible outcome, given prior experience. The individual
may not even be aware of this covert operation. (p. 148, emphasis added)
I have italicized Damasio’s phrase “the decision-making process is bi

ased toward selecting the action most likely to lead to the best possible
outcome” and underlined “given prior experience” to caution against
misinterpretation. Some people might think that this “best possible out
come” means a weighing of possible pros and cons to make a logical, ra
tional, conscious choice as to what is the best thing to do in a particular
situation. To form that interpretation would be to ignore the main point of
the quotation. Damasio is writing about the power of unconscious choices,
a biasing of choices based not on rational thought but on emotions linked
to conscious or unconscious memories of previous experiences.
Example of Unconscious Motivations

One example of unconscious motivation is shown by Jim, a first-semester
college freshman who was trying to write a take-home midterm exam
due at his 8 A.M. class the next morning.
Case Example: A college freshman
with biased motives
It was a difficult exam, and Jim was having a lot of trouble answering most
of the questions, possibly because he had not yet read even half of the chap
ters assigned for the test. Jim had put off doing any work on the exam for
several days. He had been preoccupied since an e-mail 3 days earlier from
his girlfriend back home. She wrote that she wanted to break up because he
was now too far away and she had gotten involved with someone else.
About 2 A.M., after struggling with the exam for several hours, Jim
decided to take a nap for a couple of hours and then try to finish the
exam. He set his alarm for 4 A.M. When the alarm buzzed, Jim woke up
for a few moments, turned the alarm off, and went back to sleep. He did
not wake up until 5 hours later. When he realized he had slept through
the deadline, Jim panicked. The professor had announced that he would
not accept any late exams. Recognizing that he would certainly get an F
on the midterm, Jim impulsively decided he was not ready to be in col
lege. Without discussing his decision with anyone, he packed his suit
case and left to go home, planning to stay there until the following fall,
when he would try again to go to college.
In talking with me back home about this a week later, Jim initially said
that dropping out of college was the best thing for him at that point. He
said he had been excited to go off to college, but the work seemed too hard
for him, he had not yet made any real friends, and he had really been
missing his girlfriend and his parents. He also claimed that getting an F
on the midterm would have meant failing that course, so it made no sense
for him to continue any of his courses that semester. He could see no other
way to deal with that situation. He also mentioned that in coming home
he had hoped he could win back his girlfriend’s affections. As it turned
out, she was not at all interested in getting reinvolved with him.
Jim had quit many activities before. After successfully playing Little
League for many years, he had gone out for his high school baseball team
and then quit before the first game. He had started two different ad
vanced placement courses and then dropped each of them before the final
exam. He was quick to feel unsure of himself and quick to get himself out
of any situation where he was afraid he might not do well. Given his prior
experiences, quickly escaping from anything stressful felt like the best
possible outcome for him. He was biased toward early escape from stress.
Only after several months of psychotherapy was Jim able to see that
his “accidental” going back to sleep that morning, his failure to even dis
cuss his situation with his college advisor, and his assumption that he
faced inevitable failure were not actually the best choices for him. Those
decisions were all examples of his long-standing pattern of quickly jump
ing to conclusions and fearfully choosing to run away from any stressful
situation. Only gradually could he see the various ways he might have
been able to work things out so he could have made a success of that first
semester, despite his girlfriend’s decision to break up and despite his fail
ing that exam. He returned to college the next semester after gradually
finding ways to cope more effectively with his fears.
Jim’s situation is just one of many possible examples of how people of
ten bias their decisions. They do not realize how much their actions are
based on memories of past experiences, in which, for example, they learned
to run away too quickly from what they feared. Sometimes, people give up
too soon when they feel frustrated or discouraged, or they become de
manding and aggressive to try to get what they want from others. Often,
memories and associated emotions involved in such situations remain to
tally unconscious, and the person mistakenly thinks it is obvious that what
they choose is the best action. Looking back, it is possible to discern these
processes repeatedly operating in the patterns of a lifetime of relationships.
Older Memories and Shaping of

Current Interpersonal Relationships
Most of us tend to deal with many people in our present daily life using
expectations we bring with us from our earlier experiences with other
people we have known. Without realizing it, we assume that people in
our present are very much like one or another person in our past. Some
times, people in our current lives may be quite similar in one or many
ways to others we have known, but at other times, we may assume they
are similar when, in fact, they are not.
John Bowlby (1978), pioneer developer of attachment theory, wrote
about the persistence of early experience in choices and relationships we
make throughout our lifetime. He used the term representational models
to refer to individuals’ persisting personal views of self and others—
their aggregated expectations, complex and only partly conscious, of
persons to whom they have been attached. These models or memories
include our image of who a person is and what that person wants, in
tends, and will do. They also include our picture of how the person
thinks about us, how much that person may be interested in us, how
much he or she likes or does not like us, and how much he or she will ap
prove or disapprove of us and our actions and attitudes.
Bowlby suggested that we tend to rely heavily on our representa
tional models of the persons we have been attached to during childhood
and adolescence, particularly our parents, siblings, and other family
members. These attachment figures tend to be a continuing source of ex
pectations about others whom we meet throughout our lives. He also
emphasized that each of us develops representational models of our
selves from our earlier patterns of interactions with family, classmates,
and friends we are close to. He claims that we tend to hang on to the pic
tures of ourselves that we have developed over the years of our growing
up, and we often tend to keep on using those old pictures of what kind
of person we are and how others will probably think of us and deal with
us. We are often unaware of how much we cluelessly bring our past into
our present. Here is the way Bowlby (1978) described this process:
Whatever representational models of attachment figures and of self an

individual builds during childhood and adolescence tend to persist rel
atively unchanged into and throughout adult life. As a result one tends
to assimilate any new person with whom he forms a bond—a spouse,
child, employer or therapist—to an existing model and often to continue
to do so despite repeated evidence that the model is inappropriate.
Similarly one expects to be perceived and treated by others in ways
that would be appropriate to his self-model and to continue with such
expectations despite contrary evidence. Such biased perceptions and ex
pectations lead to various misconceived beliefs about other people, to
false expectations about the way they will behave, and to inappropriate
actions intended to forestall their expected behavior. (p. 16)
These processes described by LeDoux, Damasio, and Bowlby occur

in all of us sometimes. Every one of us has times when we act or fail to
act in ways that may be puzzling to us and to others. In those situations,

our motivations may be shaped too much by unrecognized old feelings,
old patterns, and old assumptions rather than by our conscious inten
tions and rational conscious thinking about our current situation.
Emotions and Working Memory

in ADHD
For individuals with ADHD, a tendency to act without sufficient thought,
contrary to their conscious intentions, seems to be present more frequently
than for most others. Their actions are more often made impulsively, with
out adequately recognizing and fully considering what may be different in
the larger context of their immediate situation. Constrained in these ways,
persons with ADHD tend often to respond too much to whatever they are
noticing and feeling in their immediate situation, in the present moment,
while neglecting other facts and other emotions that may be quite relevant
and important. They react to many life situations as one might react while
watching a basketball game through a telescope that allows one to clearly
see a small circle of the action in the game but not the rest of what is going
on in the court with other players and various other threats and opportu
nities that may be present. They have great difficulty in keeping the bigger
picture, the larger context, and future possibilities in mind.
One example of the way emotion can affect how a person with
ADHD reacts to a situation was provided by a woman who once told me
how she dreaded Wednesday evenings. For her family, that was the
night after their Wednesday morning trash pickup. She had two teenage
sons, and the family lived in a house with a long driveway leading
down to the place where their trash was picked up early every Wednes
day morning. Her husband asked their boys to take on the job of drag
ging the trash cans down to the foot of their driveway every Tuesday
evening and then to bring the emptied cans back up the driveway after
they got home from school on each Wednesday afternoon. Often, they
forgot to bring the trash cans back in.
This mother explained that anytime her husband got home from
work on Wednesday evening and saw the trash cans still at the base of
the driveway, he would become enraged. He would call the boys to
come to him and then would get in their faces and scream at them, say
ing they were losers, irresponsible, ungrateful for what they had been
given, unwilling to help the family by doing the simple chore of bring
ing the trash cans back up to the house once a week. In his rage, he
shouted at them:
Neither of you is ever going to amount to anything! If you can’t do this

simple chore, how will you ever be able to do the bigger things? How
will you ever be able to get and hold a job? How will you ever be able to
get a wife and take care of her and your children? I’ve told you about this
so damn many times, and you don’t listen! You don’t remember, and
you don’t care! I’m disgusted! You’re both going to turn out to be a cou
ple of irresponsible losers!
The mother explained that after each time her husband scolded their
sons so harshly, he would later calm down and then mumble an apology
to the boys. She said, “I know he loves them both and would give his life
for either one of them, but when he gets wound up in one of those
Wednesday night episodes, he gets so enraged that he seems to forget
that those are his sons whom he loves and wants to protect. He really
doesn’t want to hurt them or have them believe they’re destined for fail
ure. All he knows in that moment is that he is furious with both of them
for not having done that chore.”
Any parent can lose his or her temper with a child occasionally, but
most parents, most of the time, can express their frustration to the child
without such an intense verbal attack. They can usually keep in mind
that this is their child whom they love and want to nurture and protect,
despite the frustrations of the moment. Their memory of that larger con
text allows them to avoid an excessively harsh display of rage, even
though they are feeling intense frustration and anger. Their working
memory allows them to hold in mind their love even while their anger is
taking up a lot of space in their head.
Unfortunately, individuals with ADHD often suffer from significant
impairments of working memory that frequently impact not only their
ability to remember where they have left their keys, what time they
promised to meet someone, what they have just read or heard, and what
they were about to say or do. For many, those working memory impair
ments also impact their ability to remember their love for someone
while they are angry at him or her or to keep in mind their hopes for that
person when they feel disappointed by him or her. Flooded with one
emotion in that moment, they are unable to keep in mind other thoughts
and emotions that are important and relevant for guiding their actions.
ADHD researchers have repeatedly demonstrated impairments in
working memory as a central feature of this disorder (Alderson et al.
2013; Fried et al. 2016; Kennedy et al. 2016; Martinussen et al. 2005;
Quinlan and Brown 2003), but not much has been written to clarify how
this memory works or possible causes of working memory impairments
commonly seen in ADHD.
Working Memory as a Network

Not a Structure in the Brain
Working memory is not a specific structure of tissues that can be iden
tified in imaging studies as can the cerebellum or thalamus. Rather, it is
a function of dynamic coordination between multiple neural networks
of the brain. These networks are not static. They continually self-modify
and rearrange connections with other networks throughout the brain to
rapidly route and reroute neural messages, shifting intensity and direc
tions to facilitate exchange of information within and between neural
networks of the brain.
This dynamic coordination of brain networks is somewhat similar
to, but more complex than, the dynamic electrical circuits that illumi
nate pixels in frequently shifting patterns to form colors, letters, and im
ages of action on the screen of a television or computer. Problems of
working memory are likely to result from impairments in the dynamic
functions of interacting networks that form linking interactions among
various sectors of the brain (Phillips and Singer 2010).
Recent imaging studies have demonstrated significant difficulties
with functional connectivity between various regions of the brain in
children and adults with ADHD. For example, studies have demon
strated that those with ADHD tend to have differences in the neural net
works that register how potentially rewarding a specific activity might
be. Those with ADHD have demonstrated less effective communication
in reward pathways of the nucleus accumbens, hypothalamus, caudate,
and midbrain in comparison with control subjects (Silvetti et al. 2013;
Stark et al. 2011; Tripp and Wickens 2008; Volkow et al. 2009, 2011).
These imaging studies have demonstrated less efficient signaling in the
brain circuits of persons with ADHD that monitor how appealing or re
warding specific tasks or opportunities might be.
It is difficult for most of us to appreciate the speed and complexity of
these processes involved in motivation because we tend to think of
them as identical to our conscious process of decision making. We tend
to think of motivation in very simple binary terms, as though every ac
tion, every shift of focus, were as simple as a conscious decision of “Do
you want to do this or don’t you?” The processes of motivation in the
brain are much more subtle and complex.
We understand that the visual system of the brain routinely allows
us to recognize and construct three-dimensional images of an object
even if we can see only a few aspects of the object’s shape or flickering
shadows of its movements. Without conscious deliberation and with

amazing speed, our visual cortex transforms rays of light picked up by
the cones and rods of our eyes, reflects them on our retinas, associates
these reflections with our massive catalog of memories of what we pre
viously have seen, and then constructs for us our vision of complex and
often rapidly changing scenes, including multiple objects at various dis
tances in three dimensions with richly textured colors. Shaping of mo
tivation in the brain is at least as complex as shaping of images.
Likewise, we know that our senses allow us to smell and taste many
subtle differences between the foods we eat and wines and other bever
ages we drink, readily associating these with our previous experiences
of the smell and taste of countless ingredients encountered at differing
temperatures, in multiple combinations in previous situations. The fra
grance and taste of these substances can also instantly make multiple
connections to times and places where we have had that food or drink
before in circumstances we previously found comfortable and enjoyable
or nasty and repulsive (Proust 1989).
Sometimes, we consciously recognize and identify the sensations
and are fully aware of when and where we have experienced that taste
or smell before. In other situations, we may recognize in the moment
only the associated pleasure or repulsion, but we may act on that asso
ciation nevertheless. Most of us have experienced times when we have
engaged in actions that literally or figuratively, quickly or much later,
have “left a bad taste in our mouth.”
Given that situations of daily life activate many different emotion
laden memories, there is need for the brain to sort and prioritize those
memories and associated motives. The brain requires and has ways of
scaling importance. Just as our eyes can register varying degrees of in
tensity from very dim to very bright light and our skin can report vary
ing degrees of hot and cold, so the brain can register highly variable
degrees of mild, moderate, and very intense levels of attraction and fear
attached to countless memories. These are derived from previous expe
riences—memories of our own direct experiences and memories de
rived from things we have seen happening to others or have heard
about from others or have imagined happening to us.
Working Memory and Context

All these loadings of emotion-laden memories are context dependent.
They vary according to where we are, who we are with, and what we
perceive as going on around us. Associative networks of the brain reg
ister a much more intense level of fear in response to a sudden noise or
movement when we are alone in a dark and unfamiliar place or in a sit

uation where we know others have been attacked, for example. Like
wise, these remarkable networks can arouse intense attraction if the
brain detects smells, sounds, or words that hint even slightly at possible
pleasure.
Just as the brain’s selection of memories attached to various thoughts
and perceptions are context dependent, they also are complex and often
conflicting. Frequently, emotional associations to a particular thought,
sound, smell, or other perception are derived from situations in which
that particular sensation or experience has been highly pleasurable and
rewarding. However, additional associations with that same thought,
sound, smell, or perception may be accompanied by many more associ
ations involving pain, shame, guilt, or fear. One context may pull more
associations to darker, more uncomfortable, stressful emotions, whereas
in another context, the same stimuli may stimulate strong interest and
attraction. Sometimes, such conflicts arise in the same moment, leading
us to feel strong conflict. In other situations, reactions may be more se
rial. We may be struck initially by feelings of attraction and engagement,
only later feeling delayed regret, guilt, or fear.
Given this complexity of motivations generated by the brain, how
can we understand the variations in the ability of individuals with
ADHD to exercise their executive functions from one time to another,
even for the same task? Why can a student be unable to begin studying
for an examination or start writing a paper until just a few hours before
the exam or before the deadline for submitting the paper and then per
form extremely well on the exam or writing the paper? The student did
not suddenly acquire the needed skills at the eleventh hour; those skills
were present throughout the period of procrastination. Reports from
those with ADHD indicate that such procrastination may sometimes be
due to being too busy with other required activities, but that is most of
ten not the case. Patients often report chronic inability to mobilize and
get started on tasks until they feel the situation has become an emer
gency with consequences that appear to them as likely to be very unpleas
ant or very painful.
The “appear to them” in the last sentence is important. Patients with
ADHD and their families typically report that excesses of procrastina
tion are rarely without multiple reminders or persistent nagging from
parents, teachers, employment supervisors, or friends. The problem is
not usually that individuals with ADHD have forgotten the upcoming
exam or term paper or the imminent deadline for a work project. Often,
they are repeatedly reminding themselves and/or being reminded by
others about the task that needs to be done. They may be very much
aware that the task should be done and may even feel that they want to
get it started, but they simply do not do it. They may report that they feel
urgency for the task they are avoiding, but they persist in avoiding it.
Despite their being consciously aware of the urgency, they tend not to
feel sufficient urgency until the deadline is imminent.
Some researchers have used the concept of delay aversion to describe
the tendency of many with ADHD, more than their peers, to have a neg
ative reaction to having to wait, a tendency to want to take a smaller
payoff received immediately rather than to wait for a bigger payoff that
will be received only after a delay (Sonuga-Barke 2005). A related con
cept is delay discounting, a tendency of some persons to think of a reward
or punishment as less appealing (rewards) or less frightening or intim
idating (unpleasant consequences), depending on how much farther
down the road it is likely to be encountered (Da Matta et al. 2012). In
both cases, a potential payoff or punishment is seen by the individual as
being not so much to be concerned about in comparison with whatever
payoff is likely to be available more immediately, in the here and now.
Two Factors Contributing

to Situational Specificity
of ADHD Symptoms
We return now to the question raised at the outset of this chapter. Why is
it that persons who have ADHD can focus well on some tasks in which
they have strong personal interest but are unable to do so for many other
tasks they recognize as important? How can these intra-individual dif
ferences in motivation characteristic of persons with ADHD be ex
plained? I propose that those situational differences in motivation may
be tied to two different aspects of brain functions in persons with
ADHD: at the micro level, problems in synaptic transmission, and at the
macro level, problems with dynamic coordination in working memory.
Neural Transmission Problems and

Situational Specificity of Motivation
The most basic factor contributing to the ability of persons with ADHD to
focus very well and efficiently utilize their executive functions on some
tasks while being chronically unable to focus adequately on most other
tasks is a problem of neural transmission. For many years, it has been rec
ognized that individuals with ADHD tend to chronically have insufficient
release and reloading of the neurotransmitter dopamine at synaptic junc

tions of neurons in the networks that manage executive functions of the
brain (Volkow et al. 2011). Many studies have demonstrated that treat
ment with stimulant medications improves the efficiency of neural com
munication at the synaptic gaps. Stimulants can increase the release of
dopamine across the synaptic cleft; they also slow the reuptake of do
pamine at these synapses, allowing the transmitter to sit slightly longer
on postsynaptic receptors to make a better connection. However, this in
creased dopamine release and slowed reloading is not under voluntary
control. It does not occur in response to someone else reminding the per
son with ADHD that this task is important and should be attended to. It
occurs only for those tasks in which the person has strong interest. The
heightened interest may be because that activity has brought pleasure
or other rewards to the person in the past. Or interest may be intensified
because the person fears that something he or she anticipates as being
unpleasant is likely to occur very quickly if he or she does not attend to
the task immediately. Whether for anticipated pleasure or fear, the
heightened interest generates increased release of dopamine instantly
and sustains it for as long as the intensified interest persists. However,
the individual cannot make this happen just by wishing it to be so.
In other contexts, I have explained this process with an example once
suggested to me by a patient with ADHD. He told me the following:
Having ADHD is like having erectile dysfunction of the brain. If the task
you are faced with is something that strongly interests you, if it really
turns you on, you’re “up” for it and you can perform. But if the task is
not something that really interests you, then you can’t get it up and you
can’t perform. In that situation, it doesn’t matter how much you may say
to yourself, “I need to, I ought to, I should.” You can’t make it happen.
It’s just not a willpower kind of thing. (Brown 2005a)
In persons with ADHD who do not have the benefit of stimulant

medications, transmission of neural messages tends to be relatively in
efficient for routine tasks but not for messages related to actions in which
the individual has strong personal interest. For those tasks in which the
individual has strong personal interest, the neural transmission is
quicker and more potent. The brain gives such messages higher priority.
Neural traffic related to actions in which the person has strong personal
interest (not because someone tells him or her that he or she ought to be
interested in this to get better grades or whatever else but just because he
or she is interested, for whatever reason) is usually carried efficiently.
However, for those tasks in which the person does not have strong per
sonal interest and is not especially fearful of a very unpleasant conse

quence rapidly happening if the task is not immediately attended to,
neural transmissions needed to get attention and effort mobilized are
likely to be slow and only minimally effective.
Working Memory and Situational Variability

of Motivation
The second factor that influences the ability of persons with ADHD to pay
attention to some tasks in which they have strong personal interest but not
to other tasks in which they lack that strong interest is the relative weakness
in working memory that is characteristic of many persons with ADHD.
Working memory is essential for keeping in mind relative priorities of our
various interests at any given time. Social psychological research has
shown that individuals with larger working memory capacity are gener
ally better able to deal with emotions, pleasant and unpleasant, without
getting excessively caught up in them (Schmeichel et al. 2008). They may
be better able to keep in mind mitigating factors and other relevant in
formation that protect them from becoming too immersed in the emo
tions of the moment. Those with ADHD tend to have less “bandwidth”
in their working memory functions and are likely to have more diffi
culty than others in quickly linking together various memories relevant
to doing or not doing a particular task. They are more likely to respond
on the basis of just a small part of their current situation, not adequately
taking into account the bigger picture of which the present moment is a
part. They are likely to be operating more like someone watching the
basketball game through a telescope, unable to take into account the rest
of the action on the court, the threats and/or opportunities that are not
included in the small circle of focus provided by their telescope.
An example is provided by a man who overslept one day and was
late to work. He had been up late working on a lengthy quarterly report
required by his employer. As he finished that report shortly before mid
night, his wife approached him in an attractive new nightgown, made a
romantic overture, and mentioned that she was in the mood for ro
mance. He abruptly told her that he was not interested because he was
too tired. She felt disappointed and hurt. This led her to launch into an
angry description of other times she had recently felt ignored and ne
glected by her husband. She questioned whether he still loved her and
whether he had lost interest in her and whether he was feeling more at
tracted to his new secretary. He insisted that he was simply tired from a
long and busy day. A protracted argument ensued; it was almost 3 A.M.
before they were able to resolve this situation and get to sleep.
When the husband’s alarm clock buzzed at 6 A.M., he awakened for a
moment and thought about how he felt exhausted and needed to get more
sleep before going to work. He turned the alarm off and went back to sleep,
intending to get up after another half hour. He awoke 2 hours later and
rushed to shower, dress, and get to his office. He arrived at the office 2 hours
late, just as the mandatory weekly staff meeting was concluding. Only then
did he remember that on the previous day his boss had warned him that his
job would be in jeopardy if he did not stop his frequent habit of arriving late
to work. He had not even thought about that very recent warning when he
turned off his alarm clock at 6 A.M. to get more sleep. He was too immersed
in his strong wish for more sleep and did not remember that he had recently
been warned that he might lose his job if he continued his pattern of being
chronically late to work. He lost sight of the threat to his job because his
working memory failed him. He was unable to retrieve the memory of that
important warning he had received the preceding day. He remained too en
grossed in the emotion of the moment.
Another way in which context influences motivation is illustrated in
the following example. My wife and I were on a transatlantic flight, for
tunate enough to ride in business class where mid flight the flight crew
baked chocolate chip cookies to serve only to passengers in business
seats. The fragrance of the cookies baking wafted through the cabin, and
I really wanted one. However, at that time I was on a diet trying to lose a
few pounds, and my wife was serving as the food police, reminding me to
avoid eating too many sweets. I resolved to decline the cookies and felt
proud of myself for abstaining until I noticed that my wife, sitting next to
me, was asleep...This put me in considerable conflict between my wish to
maintain my diet and my wish to eat one of those delicious cookies. I
looked again to be sure she was asleep, and she was. At that moment, the
flight attendant held out a tray of cookies and asked if I wanted one, so I
said, “Yes, please” and also asked if she would give me a second one for
my wife, who was asleep. As soon as I got the cookies, I ate both of them
and then hustled down the galley to dispose of the evidence. I didn’t
bother my wife with the facts until later in the trip, and we laughed about
it. However, I can honestly report that if she had been awake, I would
have declined the cookie, feeling somewhat deprived but also proud of
myself for sticking to my diet. This is an example of how one can have
conflicting motives and be swayed sharply toward one or the other de
pending on the circumstances of where one is and who else is present.
Summary
This chapter delves further into the “central mystery of ADHD,” which
is the puzzling fact that persons with ADHD suffer chronic impair
ments in their ability to exercise adequate executive functions in many
activities of daily life, yet they are able to exercise those same executive
functions quite well for a few specific tasks or activities that arouse
strong interest or strong fear. This mystery involves situational specific
ity of unconscious motivations.
In this chapter, I describe the importance and complexity of uncon
scious emotions in motivation for all people. I then propose that those
with ADHD tend to suffer chronic deficits in motivation for many tasks
of daily life because they suffer from chronic impairments of working
memory. The more limited bandwidth of their working memory re
stricts their ability to keep in mind the larger context, important aspects
of the situation, and the future beyond the present moment. This often
leads to inadequate motivation for tasks or activities for which their
emotions are not strong enough to stimulate heightened release of do
pamine at the involved neuronal junctions.
6
How ADHD
Develops, Sometimes
Gets Worse, and
Sometimes Improves
LIKE EYE COLOR AND HEIGHT, ATTENTION-DEFICIT/

hyperactivity disorder (ADHD) begins with genes. It runs in families.
One out of every four people who have ADHD is likely to have a parent
with ADHD, whether he or she knows it or not; the other three usually
have at least one sibling, grandparent, uncle, aunt, or cousin who has
ADHD. These relatives may not have been recognized as having ADHD
because in the old days, doctors did not know how to diagnose it. Even
today, the diagnosis is often missed because many clinicians have not
yet learned about how to recognize ADHD as we now understand it. If
you ask family members to think about which blood relatives have had
a reputation for being very disorganized or chronically struggling to
stay focused or who seemed pretty smart but did not do well in school
and then did much better after they got out of school, you may find
more than one in the family who possibly had or has ADHD.
The heritability of ADHD is based on genes. Studies that compare
identical twins (who share 100% of the same genes) and fraternal twins
(who share only 50% of the same genes) provide substantial evidence
79
that ADHD is inherited. In twin studies, researchers use a scale that

ranges from 0 to 1 (heritability index) to show how much genes contrib
ute to a trait or disorder. On that scale, 0 means that genes have no ap
parent influence on the disorder, and scores closer to 1 suggest that
genes play a major role in a person’s vulnerability to that disorder. Ac
cording to the heritability index, breast cancer is about 0.3, asthma is
about 0.4, and height is about 0.9. A review of data from 20 different
twin studies of ADHD yielded a score of 0.76 on that scale. This very
high rate of heritability makes ADHD one of the most heritable of psy
chiatric disorders (Faraone et al. 2005).
There is no one gene that causes ADHD. Scientists have found that
many different genes contribute in small ways that shape developments
in the brain, eventually resulting in ADHD. However, the effects of
genes on development of ADHD are complicated, and not all are notice
able in early childhood.
Unlike eye color, ADHD is not usually apparent from birth. Often, it
is not noticeable until the child is in preschool or in the elementary
school years, when he or she is expected to focus on learning, participate
in organized group activities, and produce assigned work. In many
cases, ADHD is not noticeable until even later. Some very bright chil
dren with ADHD are honor students in elementary school with good
behavior and high grades; their problems with ADHD-related execu
tive functions may not become apparent until they move into middle
school or beyond. Those students may begin to struggle to keep them
selves organized and to stay on top of their work only as they get into
upper grades, where they have multiple teachers, the work is more chal
lenging, and they need to keep track of many assignments and do more
homework independently. Sometimes ADHD symptoms do not appear
until the individual encounters the increased challenges of late adoles
cence or adulthood (Brown et al. 2011a).
How do genes influence an individual to develop the syndrome of
difficulties that we call ADHD? Each individual’s genes are the blue
print for development of every cell of that person’s body, including the
brain. However, genes are different from blueprints in that they are dy
namic, not static. Some genes, like those for eye color, turn on during fe
tal development, causing cell growth that remains stable. Other genes
do not become at all active until many years after the person is born.
Some genes turn on and off depending on other things going on in the
body or in the environment. The resulting changes may be very helpful
for the healthy functioning of some aspects of the individual; other
changes caused by genes turning on or off may impair functioning in
limited or in far-reaching ways.
How ADHD Develops, May Get Worse, or May Improve 81
There are three major ways in which research thus far has found brain
development and functioning to be different in individuals with ADHD:
• Brain structure and maturation

• Maturation of functional neural connectedness within the brain
• Dynamics of electrochemical communications in the brain
One important influence of genes in ADHD is the timing and rate at

which certain parts of the brain structure develop. Several imaging
studies have shown that the structure of key cognitive management re
gions of the brain tends to mature 3–5 years later in most children with
ADHD than in their peers (Shaw et al. 2007, 2012, 2013).
Brain Structure and Maturation

For everyone, the process of brain maturation starts during early child
hood with a rapid proliferation of cells in the cerebral cortex, the large
top part of the brain near the front that is the headquarters for coordi
nating the brain’s management system. This expansive cell growth
thickens the cortex. In one study, researchers performed repeated mag
netic resonance imaging (MRI) of the brains of 223 children diagnosed
with ADHD and 223 typically developing children as they were grow
ing up (Shaw et al. 2007). These images allowed researchers to monitor
40,000 points in the brain of each child to see if there was any noticeable
difference in how the brains of those with ADHD matured in compari
son with the brains of children who did not have ADHD. Shaw et al.
(2007) found no significant differences between the two groups in mat
uration of brain structures that process such elements as vision, hearing,
and movement. However, there were significant differences in the mat
uration of certain areas of the cortex, headquarters of the management
system. On average, persons with ADHD were 3–5 years slower in mat
uration of some specific areas of the cortex that are important for the
brain’s cognitive management.
The cortex is the gray matter of the brain. Within it are more than 100 bil
lion infinitesimal neurons intricately connected with each other. Develop
ment of countless new connections within the brain results in thickening.
For most of the typically developing children in the study by Shaw et al.
(2007), that thickening of the cortex peaked by about 7.5 years of age; most
children with ADHD did not achieve that peak level of brain thickness un
til about 3 years later.
A second stage of brain maturation usually begins after the thicken
ing of the cortex. Following that cortical thickening, there is a long pe
riod, usually during adolescence, of automatic pruning in the cortex to

develop more efficient circuits. This is similar to the pruning people do
with fruit trees to allow branches to develop better fruit. This second
stage also involves an increase in the surface area of the cortex and in
further development of gyri (the curvy folds and bumps on its surface).
A follow-up imaging study found that children with ADHD were de
layed in this second phase of brain development also. They tended to be
at least a couple of years delayed in the development of surface area in
their cortex when compared with those who did not have ADHD (Shaw
et al. 2012).
An important question arising from these research findings on delayed
maturation of brain in children and adolescents with ADHD is whether
and when their brain development catches up. A sample of 92 young
adults who had been diagnosed with ADHD in childhood and had brain
imaging assessment prior to age 17 years was evaluated again in young
adulthood (average age 24 years) (Shaw et al. 2013). That group was di
vided into those who still met diagnostic criteria for ADHD (40%) and
those whose ADHD symptoms had improved so they no longer met di
agnostic criteria (60%). Brain images from both of those ADHD groups
were then compared with brain images from 184 typically developing
young adults in the same age range.
In participants whose ADHD had remitted, the cortex had thickened
just as it had in the typically developing group of the same age. Their brain
development caught up. None of those whose ADHD inattention symp
toms had continued into that point of young adulthood had any significant
thickening of the cortex. Up to that point, their overall cortex remained sig
nificantly thinner than that found in the typically developing group and in
the group whose ADHD had remitted (Shaw et al. 2013).
The study by Shaw et al. (2013) cannot tell us how many, if any, of
those young adults whose ADHD symptoms continued into their mid-20s
might experience normal thickening of their cortex in later years. Proal et
al. (2011) provide a longer-term view. In their study, researchers followed
up on a group of boys, 59 of whom had been diagnosed with ADHD (com
bined type) in childhood and 80 others who as children were found not to
have ADHD. Brain imaging was done on these participants 33 years after
they had been diagnosed in childhood. Average age of the group at fol
low-up was 41 years. Imaging showed that all of those diagnosed with
ADHD in childhood had reduced gray matter in several parts of the brain
that are critical for control of attention, regulation of emotion, and moti
vation. Those whose ADHD had remitted by the time of imaging showed
more thickening in some specific regions of cortex than did those who still
fully met diagnostic criteria for ADHD after 33 years.
More recent MRI research on cortical thickness studied 306 adoles

cents and young adults with ADHD and compared them with 184 healthy
control subjects; average age was 17 years (Schweren et al. 2015). The re
searchers found that those with ADHD showed significantly thinner cor
tical tissue than those without ADHD, particularly in the temporal and
limbic (middle and lower) cortical regions, areas that play an important
role in memory, language, and emotions. That study also checked to see if
there were any differences in cortical thickness between persons with
ADHD who had been taking stimulant medication and those with
ADHD who had not. Results showed no differences in cortical thickness
between those who had used medication for their ADHD and those who
had never used medication.
Although multiple imaging studies have now demonstrated signif
icant patterns of cortical thinning in samples of children, adolescents,
and adults with ADHD versus those without ADHD, much remains to
be learned about how those small but persistent differences in brain
structure and development are related to the impairments characteristic
of ADHD. There are some inconsistencies in these studies, but it does
seem clear that there is a pattern of difference in development of cortical
tissue for those with ADHD. Interestingly, some studies have found a
somewhat similar type of cortical thinning in slightly different cortical
regions of adolescents and young adults with autism spectrum disorder
(Wallace et al. 2015). A more recent cross-sectional mega-analysis in
volving over 1,700 individuals with ADHD and more than 1,500 with
out ADHD used MRI scans from 23 research centers to compare the
volume of various brain structures below the cortex as well as full intra
cranial volume of those in the two groups (Hoogman et al. 2017). Results
from this sample, which included individuals ages 4–63 years, showed
that those with ADHD tended to have smaller overall intracranial vol
ume and smaller volume of a variety of subcortical structures such as
the accumbens, amygdala, and hippocampus. Differences found were
not huge, but they were significant. Life span modeling of the data sug
gested that these differences were related to delay of maturation. Those
differences were more marked in children with ADHD than in adults
with ADHD. Data also showed that previous use of medication for
ADHD and the presence of comorbid disorders did not affect the re
sults. These findings indicate that it is not just the cortical areas of the
brain that are delayed in maturation for those with ADHD; develop
ment and maturation of the subcortical structures and overall brain vol
ume also tend to be delayed in those with ADHD (Hoogman et al. 2017).
Another aspect of the brain that apparently differs in persons with
ADHD is the development of the brain’s white matter. White matter is a
complex network of axons, neural “wiring” underneath the gray matter

of the cortex, that provides extremely rapid communication from one
part of the cortex to another and from the cortex to other regions of the
brain that lie beneath the cortex. White matter is sometimes referred to
as “the subway of the brain” because of its rapid transit of neural signals
below the surface of the cortex. It makes up about half of the brain’s total
mass. White matter is studied not with MRI but with a newer technique,
diffusion tensor imaging, that measures communication along white
matter tracts by testing the integrity of fluid flow within the white mat
ter connections.
One study assessed for white matter differences in brains of adult
men diagnosed with or without ADHD during childhood 33 years ear
lier (Cortese et al. 2013b). Of those men, 51 had been diagnosed with
ADHD in childhood, and 66 had been found not to have ADHD. Diffu
sion tensor imaging (DTI) indicated that the group of men diagnosed with
ADHD in childhood showed decreased white matter coherence 33 years
later, whether or not they still met diagnostic criteria for ADHD in adult
hood. The white matter tracts that showed inefficiencies included a num
ber of tracts that connect to gray matter important for the brain’s
management system. Although this is just one study, its comparison of
men with a history of ADHD in childhood with control subjects suggests
that differences in white matter structure are an enduring trait of persons
with ADHD.
Maturation of Functional
Connectedness Within the Brain
The cortical imaging and white matter studies discussed in the previous
section all reported on structural differences in brain development of
persons with ADHD versus those without. Other studies have used
functional MRI (fMRI) to study the interactive connectedness of two dif
ferent regions of the cortex in adults who had been carefully diagnosed
with ADHD in childhood (Mattfeld et al. 2014; Sporns 2011, 2012; Sri
pada et al. 2014). These studies assessed not how well those structures of
the brain’s management system were built but how effectively they in
teracted for mutual communication.
Research has demonstrated that the human brain is organized into
large functional networks over which patterns of communication from
one region of the brain change rapidly depending on what is currently
going on within the brain in response to what is happening in the im
mediate environment. Scientists study these networks with fMRI to see
what patterns emerge as regions activate and communicate with other

regions to engage or reconfigure to shift attention and actions (Sporns
2011, 2012).
In one study of adults who had been diagnosed with ADHD during
childhood, researchers studied 13 participants who still had full-blown
ADHD in adulthood and 22 who no longer had it when evaluated as
adults (Mattfeld et al. 2014). The fMRI of those with a history of ADHD
in childhood were compared with one another and with brain images of
17 persons who had no history of ADHD. The aim of the study was to
assess active connectedness while the brain was awake but not busy
with any specific task.
Results showed that active connectedness between two regions that
are important for coordinating management activities of the brain (pos
terior cingulate and medial prefrontal cortices) was very similar for
those whose ADHD had remitted and for those who never had ADHD.
Active connectedness between the two critical regions of the brain was
significantly reduced in persons who had persistent ADHD but not in
those who never had ADHD or whose ADHD symptoms had gone
away (Mattfeld et al. 2014).
Attentional problems in ADHD often involve problems in the com
petitive balance between functional networks. One important network
focuses primarily on one’s own thoughts and wanderings of mind; this
is called the default mode network. Other networks focus more on process
ing information outside the individual in order to focus on various ex
ternal tasks as they arise. From childhood to early adulthood, most
individuals show a predictable pattern of maturation, with increasing
ability to focus on external tasks. Research has shown that persons with
ADHD often have difficulty pulling out of the default mode network to
focus consistently on external tasks; they repeatedly tend to “space out”
and drift back into default mode even when they are trying to pay at
tention (Querne et al. 2014; Sidlauskaite et al. 2016).
One fMRI research project studied 275 children and adolescents di
agnosed with ADHD and compared their functional connectivity pat
terns with those of 288 typically developing participants of similar age
(Sripada et al. 2014). The study predicted that children with ADHD
would demonstrate a maturational lag in the patterns of connectivity
between their default mode network and two other networks that focus
more on external tasks. Results clearly demonstrated that compared
with persons without ADHD, those with ADHD had a significant age
related delay in maturation of their ability to make and maintain activa
tion of their task-focused networks. Their diminished control of these
connections caused excessive drifting off during demanding tasks, ex
cessive distractibility, and considerable inconsistency in their ability to

do tasks. These differences were determined not by their overt behavior
but by fMRI study of the patterns of activation in specific brain regions.
Moreover, those participants who were rated in advance of the study as
having more severe problems with inattention demonstrated greater
maturational lag in patterns of functional connection between their de
fault mode network and their other two task-focused networks (Sripada
et al. 2014). This study provides much valuable information, but it does
not provide any data on whether or not and how much this matura
tional lag in functional connectivity improves over time for persons
with ADHD. That question awaits further research.
Dynamics of Electrochemical
Communications in the Brain
The third area where research has demonstrated differences in brains of
those with ADHD is the process of communication between groups of
neurons that compose the networks of the brain. To grasp how ADHD
can impair electrochemical communication in the brain, it is necessary
to understand the basic principles of how neurons communicate (more
information about this process is presented in Chapter 10, “Practical As
pects of Medication Treatments for ADHD”).
The building blocks of the human cortex are neurons, tiny cells that are
only one-millionth of an inch across. Each neuron has a cell body on
which develop thousands of tiny branches called dendrites; these den
drites receive information from other neurons. Each neuron also has one
extension, called an axon, for sending information out to other cells; axons
can range in length from less than a millimeter to more than a meter long.
Neurons make contact with other neurons at junctions called synapses.
Every neuron establishes 1,000 or more synapses with surrounding neu
rons. Neurons are not actually wired together; they do not touch each
other.
At each synapse, there is a tiny gap between the back end of one neu
ron and the front end of the next. The whole network system works on
low-voltage electrical impulses. Each of the messages carried between
neurons is a tiny electrical charge of about 0.1 volt. As this moving
charge reaches each synapse, it has to jump the gap like the spark of a
spark plug. This jump across each synaptic gap depends on release of
microdots of chemicals manufactured in each neuron.
Most neurons release just one specific transmitter chemical, although
some make and release more than one. Each time a message-carrying
electrical impulse zips up to a synapse, that neuron releases microdots of

its transmitter chemical, which allows that electrical impulse to jump
across the synaptic gap to bind to receptors on the adjoining neuron,
where the message may be carried forward to another neuron. This re
lease can occur 1–100 times per second. If the electrical impulse crosses
to open receptors, it will continue to move rapidly along to the next syn
apse and possibly many more circuits and branching connections; if the
electrical impulse does not cross, it may simply diminish, blocked from
further action.
In milliseconds after a transmitter chemical has been released, it is
dissipated or pulled back into the sending neuron by proteins called
transporters that act like little vacuum cleaners, rapidly sucking the
transmitter chemical back in and repackaging it so it will be ready to be
released again. This reuptake clearance of the transmitter chemical is es
sential. Without it, the system would be jammed.
Persons with ADHD tend to suffer from one or both of two problems
with this electrochemical transmission process. The first problem is that
the reuptake sometimes happens too quickly, so the transmitter does
not connect sufficiently with the receptors to move the signal forward.
Both of the two types of stimulant medications proven effective in alle
viating ADHD symptoms, methylphenidate and amphetamine, have
one primary function: they slow down the reuptake back into the trans
porters by fractions of a second, just long enough to improve chances of
a good connection.
The second problem that may impair electrochemical communica
tion in persons with ADHD is that there may be insufficient strength of
the neuronal signal to get the message across the synapse. One type of
stimulant medication shown to be effective for alleviating ADHD im
pairments not only slows reuptake, it also causes some increase in the
amount of neurotransmitter released, which may facilitate a stronger
signal; that medication is dextroamphetamine.
The effectiveness of medications in improving communication be
tween neurons of the brain’s management system provides the most im
pressive evidence of how the impairments of ADHD are linked to
problems in communication within the brain. Over recent decades, hun
dreds of research studies have demonstrated that methylphenidate
and/or dextroamphetamine can significantly improve cognitive and
behavioral functioning for most children and adults with ADHD
(Swanson et al. 2011). These medications cure nothing! They do not fix
the problem of ADHD. However, for about 80% of persons with ADHD,
these medications reduce ADHD symptoms and improve functioning
during the hours of the day when the medication is active. For some, the
improvement is huge. For others, it is substantial but not huge. And for
about 20% of those with ADHD, current medications for ADHD are not
helpful or cause side effects that require stopping use of the medication.
Several different types of research have demonstrated how stimu
lant medications affect brain functioning in persons with ADHD. Sev
eral fMRI studies of children and adults have shown that stimulant
medication can alleviate excessive distractibility typical of many with
ADHD by reducing excessive drifting into default mode and strength
ening task-focused networks (Peterson et al. 2009). Other fMRI studies
of children with ADHD have shown that stimulant medication normal
izes the attentional network and improves motivational networks for
tasks (Rubia et al. 2009, 2011; Wong and Stevens 2012).
Positron emission tomography (PET) studies have demonstrated
that stimulant medications can facilitate engagement of external task fo
cus and deactivate the default mode network to reduce task disruption
by excessive distractibility (Volkow et al. 2008, 2012). Other PET studies
have shown that stimulant medications, when active, can enhance mo
tivation for tasks that otherwise are uninteresting (Volkow et al. 2004).
PET studies have also shown that methylphenidate and amphetamine
in clinically appropriate doses can increase the amount of neurotrans
mitters such as dopamine and norepinephrine released into the synapse
to improve signaling between neurons in specific circuits (Villemagne et
al. 1999; Volkow et al. 2009).
Up to this point in this chapter, I have focused on what has been
learned thus far about development of the brain, patterns of functional
connectivity in the brain of individuals with ADHD, and electrochemi
cal communication between neurons. In the remainder of this chapter, I
focus on questions of when and how ADHD tends to get worse and/or
better.
How ADHD Sometimes Gets Worse

When we say that a person’s ADHD has gotten worse, what we usually
mean is that the person’s executive functions, his or her ability to man
age himself or herself, have not yet developed enough to meet task re
quirements usually expected for a person of that age. As a child gets
older, family, teachers, friends, and the wider community increase their
expectations for how much a person is able to demonstrate adequate
self-management. If the discrepancy between what that individual and
most other persons of similar age are able to do is too great, people tend
to say that he or she is behind in his or her development.
ADHD is a syndrome of impairments in certain brain functions that

may cause more or less difficulty, depending on what that person needs
to do in daily life. It is important to keep in mind that ADHD is not like
an infection or a tumor that gets worse or better. It is a syndrome of im
pairments of the brain’s development and cognitive functioning. To
think about such impairments always involves the question “Impair
ment for what?” In Chapter 4, “Ways ADHD Can Impair Functioning at
Various Age Levels,” I describe some of the ways ADHD tends to im
pair certain functions in affected persons as they encounter tasks that
they are expected to perform by a specific age. For example, a young
child in preschool or kindergarten is not expected to be able to sit at a
desk and do written assignments. If a child with ADHD in fourth grade
is consistently unable to work independently on that task, the problem
is not really that his or her ADHD has gotten worse. The problem is that
the child’s ability to master the demand for increased attention and self
control has not improved as much as is usually expected for that age.
Perhaps it would make more sense to ask “What factors make a per
son’s ADHD more problematic?” than to ask “How does ADHD be
come ‘worse’?” A number of factors may make an individual’s ADHD
symptoms become more problematic at a particular time of life or in
particular situations. Some of these include the following:
• Being required to undertake new challenges without sufficient

support
Most people would not expect or allow a 3-year-old child to cross
a busy street alone. A child that young would not be expected to be
able to look carefully at traffic coming from both directions, to accu
rately estimate the speed of oncoming vehicles, and to move carefully
to cross when there is adequate space to get across safely. Any rea
sonable adult would want to provide careful assistance to help that
young child get safely across the street until the child has matured
enough to learn, remember, and use the skills needed to safely cross a
busy street alone. We also know that some children need much lon
ger to develop these skills than do others.
For some children with ADHD, academic skills such as learning to
read, preparing for a spelling test, writing a book report, and keeping
track of homework assignments are acquired as readily as for most
others of similar age. However, for some, such tasks may be as chal
lenging as it would be for a 3-year-old to cross a busy street alone.
Some children with ADHD are very quick to pick up academic skills,
but they consistently struggle more than most of their peers with so
cial skills. They are slower to pick up cues from others about when
they are being too pushy or too demanding. They feel chronically be
wildered about how to respond to classmates’ teasing or how to get
others to let them join in a conversation or a game. They may repeat
edly be too bossy and be excluded by playmates, or they may simply
retreat into solitary activities, avoiding the risk of peer rejection by
immersing themselves in playing video games.
Some children with ADHD need much more support from parents
or teachers for doing their schoolwork and/or managing social inter
actions. This need for extra support may emerge early in preschool
years, or it may not become noticeable until the child enters middle
school or high school, when more independent self-management is
expected. For some, the need for extra support does not emerge no
ticeably until the adolescent is preparing to move away from home to
go to college. For those who need such support and do not receive it
or who receive too much support and do not have ample chances to
learn to manage for themselves, such activities at various stages of
development may become almost as perilous as trying to cross a busy
street before they have learned how to do it.
• Being criticized or punished repeatedly or harshly for failures they

cannot adequately control
Because children and adolescents with ADHD often fail to meet the
usual expectations for their age, many are subjected to what they ex
perience as endless criticism or harsh punishment from teachers, par
ents, siblings, and/or peers. “Why do you always keep doing what
I’ve asked you repeatedly to stop doing?” “You keep promising that
you will write down your assignments in your plan book, and then
you keep coming home without doing it!” “Why should I keep help
ing you with your homework when you don’t even bother to hand it
in and get credit for it?” “You spend hours intently focused on playing
your video games, but you claim you can’t focus for just 20 minutes on
doing your social studies homework.”
Some children and adults report a long history of being told fre
quently while growing up that they were hopelessly lazy, stubborn,
and stupid and destined for a life of failure. Usually, such verbal at
tacks result from intense and persistent frustration experienced by
parents or others mystified by the child’s seeming refusal to do what
is expected, despite a variety of repeated efforts by the adult to en
courage appropriate behavior. Such frustration is often intensified as
the adult witnesses the child showing strong ability to focus and
work persistently on a few self-selected tasks while consistently act
ing incapable of devoting comparable attention and effort to tasks the
adult views as important. This is the result of parents not under

standing the “mystery of ADHD” described in Chapter 1, “Basic
Facts and the Central Mystery of ADHD.”
• Suffering from additional emotional, cognitive, or behavioral

problems that may be co-occurring with ADHD
Individuals with ADHD have a greatly increased likelihood of
suffering from one or more psychiatric disorders at some time in their
lifetime than do most others. One study of children with ADHD
found that 62% had at least one other psychiatric disorder, whereas
only 19% of population-based control subjects had any such disorder
by the same age (Yoshimasu et al. 2012). This is a threefold increased
risk of a comorbid disorder for those with ADHD. More than one
third of the children with ADHD in that study had two or more co
morbid disorders, whereas just 8% of the control subjects had more
than one. A nationally representative study found that adults with
ADHD were more than six times as likely as the comparison sample
to have an additional psychiatric disorder (Kessler et al. 2005, 2006).
This pattern of elevated risks for co-occurring disorders among
persons with ADHD is described and explained more fully in Chap
ter 7, “How and Why Other Disorders Often Co-occur With ADHD.”
In this chapter, the current point is simply that for many individuals,
ADHD impairments are made worse by their struggles with exces
sive anxiety, persistent depression, compulsive behaviors, difficulties
with mood regulation, learning disorders, or other psychiatric disor
ders that may be transient, recurrent, or persistently disruptive of
their ability to perform the tasks of daily life.
One comorbid problem that warrants special mention is excessive
use of alcohol and/or other drugs. A study based on pooled samples
of more than 4,000 persons with ADHD and more than 6,000 control
subjects without ADHD assessed at an average age of 18.9 years
showed the magnitude of difference between these groups. Those
with ADHD had 1.7 times the risk of a substance use disorder with al
cohol, 2.05 with cocaine, 2.29 with marijuana, and 2.84 with nicotine.
Overall, those with ADHD had more than two and a half times the
risk of having a substance use disorder with one or more of these ad
dictive substances by early adulthood (Lee et al. 2011).
For many persons with ADHD, the overuse of alcohol, marijuana,
or other drugs begins with an effort to self-medicate. Often, they strug
gle daily with feelings of frustration, embarrassment, disappointment,
or shame resulting from their ADHD impairments. Occasional use of
these substances may, for a time, bring welcome, although very tem
porary, relief from these painful emotions. The problem is that occa
sional use can readily lead to more chronic use, which can rapidly lead
to a persistent cycle of addiction from which it may be extremely diffi
cult to recover. Addiction to these substances can result in worsening
of ADHD impairments in multiple aspects of schooling, employment,
social relationships, and other areas of daily life.
• Stresses resulting from environmental adversities

Although the primary cause of ADHD is genetic, adverse envi
ronmental factors may have considerable negative impact on the life
experience of children and adults with ADHD. Examples of environ
mental adversities include serious medical or psychiatric illness of a
parent or other close family member, domestic violence, living in a
dangerous neighborhood, separation or divorce of parents, layoff or
loss of employment, multiple changes of residence, lack of or loss of
health insurance, and serious disability or death of a parent or other
close family member.
Such adversities may occur in isolation with just transient effects fol
lowed by full recovery. In other cases, adversities may be persistent and
may trigger additional adversities. For example, if a parent who has
been the primary wage earner for the family suffers a major injury or
protracted disabling illness, the parent could lose his or her job and with
it health insurance for himself or herself and the family; this could also
result in eviction, forcing a move into a more dangerous neighborhood.
Although such adversities can create overwhelming difficulties
for any family, their impact may be compounded in a family in which
one or more family members have ADHD; the difficulties can worsen
considerably if one or both parents have ADHD and are trying to
cope with the added stress that results from raising children with
ADHD. One study of more than 200 adult patients with ADHD
found that those whose ADHD symptoms were more severe tended
to have more major adversities than did those whose ADHD symp
toms were less impairing (Garcia et al. 2012). One secondary effect of
such difficulties is that some adolescents in families suffering signif
icant adversities feel an obligation to remain at home longer than
they might otherwise, sometimes sacrificing their own educational
or employment opportunities to provide economic and/or emo
tional support to parents, siblings, or other family members.
• Bodily changes of aging along with their ADHD symptoms

Many discussions of ADHD refer to it as a developmental disor
der, but generally, the focus of such discussions is limited to the first
decade or two of life; they do not encompass the full range of devel
opment across the life span. Yet the few studies that have explored
ADHD during adulthood, especially those that have looked at
midlife and beyond, clearly indicate that for those individuals whose
ADHD persists into middle adulthood and beyond, significant im
pairments tend to remain and sometimes worsen.
One population-based study of more than 2,000 men and women
ages 47–54 years found that 6.2% reported significant symptoms of
ADHD; no difference in ADHD symptoms was found between men
and women in this sample (Das et al. 2012). Evaluation of those who
reported significant ADHD impairments found that those individu
als were less likely to be employed full-time, struggled more with
physical health problems, and reported more problems in personal
relationships and in their personal finances as well as lower quality
of social life and well-being.
With or without ADHD, there are a number of physical changes
associated with aging in both males and females. Imaging studies
have demonstrated age-related decline in various elements of the
brain that provide infrastructure for executive functioning, even for
healthy adults without ADHD (Backman and Farde 2005; Gazzaley
and D'Esposito 2005; Raz 2005). Volkow et al. (1996) found a 6.6% de
crease per decade of life in availability of dopamine transporters in
healthy volunteers. Age-related decline in brain dopamine activity
even in healthy volunteers has also been documented in several other
regions of brain important for executive functions.
White matter decreases in the brain are also associated with aging
in the general population. One study found that the total length of
white matter fibers decreases by 10% per decade of life in the general
population, up to a total decline of about 45% by age 80 years, with
about a 16% greater average decline in females (Marner et al. 2003). It
should be noted, however, that these percentages of decline in the
general population are based on averages that may mask consider
able variability among various individuals.
Very little research has assessed ADHD in the geriatric population.
Many health care practitioners tend to assume that any attentional
difficulties experienced by elderly individuals are due simply to the
slow degenerative processes of aging or, possibly, to the early stages
of dementia. Adult patients sometimes fear that their ADHD predis
poses them to onset of Alzheimer’s or some other variety of demen
tia. Currently, there is no evidence to support that assumption.
ADHD in the older population may be mistakenly diagnosed as
mild neurocognitive disorder, a disorder that involves some cogni
tive decline that does not interfere with the capacity for independence
in everyday activities. Mild neurocognitive disorder is sometimes,
but certainly not always, a prelude to onset of dementia. Screening for
ADHD in any elderly person who presents with symptoms of mild
neurocognitive disorder may be helpful not only for increasing un
derstanding of possible relationships between these two disorders
but also for identifying adults whose cognitive impairments may be
due to lifelong problems with ADHD rather than to geriatric deterio
ration (Ivanchak et al. 2012).
Changes associated with menopause are an aspect of aging that is
associated with cognitive impairments similar to ADHD. Women
with no childhood history of ADHD, many of them well-educated
and high-functioning businesswomen and professional women, re
port onset of ADHD-like impairments of working memory, organiza
tional skills, and ability to sustain focus that appear coincident with
their decline of estrogen and cessation of their menses. This associa
tion makes sense in that estrogen is one of the primary modulators of
the release of dopamine in the female brain. Insufficiency of dopa
mine in the brain networks that manage executive functions is one of
the major problems associated with ADHD. Studies published by
groups at Yale and the University of Pennsylvania have demonstrated
that medications used for treatment of ADHD may help to alleviate
these midlife-onset impairments of executive functions (Epperson et
al. 2011, 2015; Shanmugan et al. 2017).
• Lack of appropriate diagnosis and treatment

Another factor that may contribute to increased impairment from
ADHD is lack of appropriate diagnosis and treatment. Among chil
dren in the United States ages 4–17 years who have been diagnosed
with ADHD, approximately 17.5% received no treatment for their
ADHD. However, there is great geographical variability in the avail
ability and use of treatment for this disorder. An analysis of treatment
patterns in the United States found that the percentage of children
with ADHD who received treatment ranged from a low of 2% in
some states to a high of 10.4% in others (Visser et al. 2014).
One survey reported that 49.7% of adults in the United States di
agnosed with ADHD had received at least some professional care for
emotional problems, but only 10.9% of those had received treatment
specifically for ADHD. For most, treatment was given for anxiety, de
pression, or some other psychiatric problem, without treatments
likely to be directly helpful for alleviating ADHD impairments
(Fayyad and Kessler 2015).
How ADHD Sometimes Improves
• Brain development may be delayed but then catch up.

As was mentioned in the section “Brain Structure and Maturation,”
delays in brain development characteristic of ADHD sometimes im
prove. Shaw et al. (2007) found that the usual pattern of cortical pro
liferation followed by pruning to develop more efficient circuits
tended to be delayed by approximately 3–5 years in persons with
ADHD. Several of the imaging studies described in that earlier sec
tion of this chapter reported on participants who were found to have
ADHD in childhood but no longer met criteria for ADHD when they
were evaluated in adulthood. It is not unusual for children who man
ifest ADHD symptoms of hyperactivity and/or impulsivity to out
grow those symptoms during early adolescence, but for 70%–80% of
those with ADHD symptoms in childhood, impairments of executive
functions related to attention tend to persist into adulthood. This
means that for 20%–30% of children with ADHD, ongoing, although
belated, brain development eventually improves functioning.
The answer to the question of how long ADHD impairments per
sist past childhood depends on how persistence is defined. Biederman
et al. (2010a) found that adults who were treated for ADHD diag
nosed in childhood tended to fall into one of three categories: 1) full
syndrome persistence (fully met all of the official diagnostic criteria
for ADHD), 2) symptomatic persistence (met more than half of the of
ficial diagnostic criteria for ADHD), and 3) functional impairment
(did not meet official diagnostic criteria but were continuing to take
medication for ADHD).
Using these categories, a follow-up study of boys diagnosed with
ADHD found that when they reached their early 20s, 35% of them
still met full diagnostic criteria, 22% had symptomatic persistence,
6% were in the functional impairment group, and 22% no longer fit
any of the three categories for continuing to have ADHD impair
ments (Biederman et al. 2010a). A study assessing girls diagnosed
with ADHD found that 33% continued to meet full diagnostic crite
ria, 29% met the partial symptoms criteria, and 33% were no longer
impaired by ADHD (Biederman et al. 2010c, 2012).
• Supportive relationships with particular family members, teach

ers, mentors, or friends provide guidance and encouragement.
Just as adversities within the family or community may compli
cate and impair the development of children, adolescents, or adults
with ADHD, an ongoing relationship with a particular parent, grand

parent, older sibling, or other family member may provide emotional
support and stabilizing guidance for someone with ADHD. In some
situations, it may be not a family member but a particular teacher,
coach, neighbor, therapist, or perhaps even a peer who becomes a
close friend, confidant, and advisor to help the growing person with
ADHD feel recognized, appreciated, and encouraged to deal with
frustrations, avoid potential trouble spots, and develop his or her per
sonal strengths. It is difficult to overestimate the value and benefits
that such a relationship can provide at critical points in the life and de
velopment of an individual with ADHD.
• After completion of basic schooling, some individuals find success

in work that better fits their interests and skills.
Usually, the most difficult times for persons with ADHD are their
years from middle school through the first few years after high
school. Those are the years when students are faced with the widest
range of tasks to do and the least opportunity to escape from the tasks
that they struggle with or find to be boring. As they progress in their
education, some who are fortunate may discover areas of study in
which they have strong interest and abilities. They may then be able
to progress to more specialized study in those areas, which may even
tually lead them to a career for which they are particularly suited.
Some students who are especially strong in quantitative thinking
and data analysis but struggle with reading or writing papers may
move into studies in accounting, finance, or computer science, where
they can develop their specialized strengths without pressure to con
tinue with intensive work with words. Likewise, some who struggle
with math while having strengths in verbal communication may
meet the minimum requirements for study of math while developing
their skills in other areas that depend more on use of oral or written
language. Others may specialize in technical, mechanical, artistic, or
scientific domains that do not require work in areas in which they are
less competent.
In some work settings, one can delegate to others tasks that are
problematic for oneself. For example, a tradesman who is skilled in
doing construction or plumbing or electrical work but struggles to
keep up with billing and office tasks may develop his business suffi
ciently to hire a part-time or full-time secretary or office manager
who can respond to phone inquiries, schedule appointments, and
manage billing and bookkeeping tasks, leaving the tradesman to de
vote himself fully to the work he does best. A business executive may
fulfill major responsibilities for planning and managing diverse opera

tions of her business organization and demonstrate excellent leadership
skills, while depending heavily on the support of an administrative as
sistant who helps to organize her incoming communications, plan her
schedule, and manage daily operations.
• Some individuals develop a relationship with a partner in which

each can complement the strengths of and help compensate for the
weaknesses of the other.
In adulthood, some individuals with ADHD are able to develop
and maintain a relationship with a partner in a work situation or in
family life who is able and willing to take care of some aspects of life
that the person with ADHD finds more difficult. At the same time, the
partner benefits from the contributions of the person with ADHD. For
example, some businesses thrive with a leadership team in which one
member manages production of a product or service while the other
member manages marketing and sales of the product or service. In
some marriages, one partner may take primary responsibility for
managing the household and family finances, while the other takes a
lesser share of those responsibilities and contributes primarily to sup
porting the family by generating income. Difficulties that often
emerge with such shared responsibilities, especially in relationships
in which one or both partners have ADHD, are discussed in Chapter
9, “Emotional Dynamics in Individuals, Couples, and Families Cop
ing With ADHD.”
• Some individuals who have ADHD complicated by another disor

der may recover from that other disorder and thus be better able to
manage their ADHD.
One example of such recovery is the individual who has struggled
with excessive drinking or excessive use of marijuana or other drugs,
perhaps during the late teens and early adulthood, and then is able to
recover from that addiction and maintain abstinence or adequate
control over the excessive substance use. Research indicates that a
majority of those addicted quit using illegal drugs by age 30 (Hey
man 2013).
For those seriously addicted to drugs or alcohol, such recovery is
not easy to gain or maintain, but many do manage to put their exces
sive drinking or drug use behind them as they enter their 20s or 30s.
This might occur after a stint in a rehabilitation program or sustained
participation in a 12-step program or other treatment program, but
often it occurs without professional assistance (Heyman 2013). Usu
ally, the first few years of recovery are the most difficult, as the indi
vidual struggles to cope with a variety of emotional problems that
may have been the initial precipitants of the excessive substance use.
In some cases, recovery is helped substantially by the individual’s
finding productive work, which provides satisfaction and financial
rewards that give the person in recovery motivation to continue to
sustain their recovery.
Another factor that helps some persons who have substance use
disorders, persistent depression, or excessive anxiety is finding
someone with whom they are able to develop a close friendship or
perhaps even a life partnership. Finding and sustaining a mutually
beneficial relationship with someone can be a strong factor in helping
individuals make important changes in their previous maladaptive
lifestyle.
• Some individuals develop compensatory strategies that allow

them to deal with some of their ADHD-related impairments.
Some persons with ADHD eventually find ways to develop habits
or routines that prevent their ADHD symptoms from disrupting their
lives. Such compensatory strategies can be as simple as consistently
placing one’s keys in a particular place beside the door immediately
on entering the house or utilizing reminders on one’s cell phone for
help in remembering to take pills on schedule each day. Other strate
gies may include maintaining an electronic or day-timer calendar for
keeping track of all appointments and utilizing a “To Do” list with
each item assigned a 1, 2, or 3 priority value and a set time for review
ing and revising that list once or twice each day to monitor progress
and keep the task list and appointment schedule within manageable
bounds.
Another strategy some persons with ADHD find helpful is to em
ploy an ADHD “coach” who has been trained to help those with
ADHD identify areas of difficulty in their daily functioning and then
to provide assistance with developing better coping strategies to
manage specific problems. The coach should also provide frequent
phone or face-to-face accountability monitoring and support for the
stated goals.
• Some individuals are fortunate enough to receive adequate assess

ment and effective treatment for their ADHD with or without co
occurring disorders.
An important factor that can help most persons with ADHD is
finding and working with an adequately trained medical or mental
health professional who can provide adequate assessment and treat

ment for ADHD symptoms and any co-occurring disorders. Many
professionals claim that they can provide such services, but it is not
always easy to locate an adequately trained professional who is ac
cessible both in terms of getting an appointment within reasonable
travel distance and affordability of the necessary services. Some med
ical insurance plans provide adequate coverage for such assessments
and treatments; others do not. However, even when cost is not a prob
lem, finding the right clinician and getting needed appointments can
be quite difficult.
Even when a competent clinician is available, there is still a need to
clearly assess the ADHD impairments, to tailor an effective plan for
treatment, and to sustain that treatment relationship for adequate
monitoring and adjustments of the treatment process. Elements of
what constitutes an adequate assessment and treatment program are
discussed in Chapters 10 and 11.
Summary
This chapter begins with an explanation of the primary cause of ADHD:
it is genetic. This disorder is highly heritable; however, what is inherited
is not the disorder itself but vulnerability to the disorder. Environmental
factors play a significant role, directly and indirectly influencing brain
development and functioning. Several major ways in which research
has demonstrated that brain development and functioning in individu
als with ADHD differs from those who do not have ADHD are also de
scribed: 1) brain structure and maturation; 2) maturation of functional
neural connectedness within the brain; and 3) dynamics of electrochem
ical communications in the brain.
ADHD is not a static condition. Across situations and over the
course of a lifetime, sometimes it gets worse and sometimes it gets bet
ter. This chapter outlines six factors that may cause ADHD impairments
to worsen and seven factors that may help to improve the functioning of
those with ADHD in ways that significantly enhance their functioning
and reduce their impairments in daily life.
7
How and Why Other
Disorders Often
Co-occur With ADHD
MOST CHILDREN, ADOLESCENTS, AND ADULTS

who have attention-deficit/hyperactivity disorder (ADHD) also have one
or more additional learning or psychiatric disorders at some point in their
life. Sometimes, both ADHD and another disorder appear in early years.
The Collaborative Multisite Multimodal Treatment Study of Children
With Attention-Deficit/Hyperactivity Disorder enrolled 579 children ages
7–9 years who had ADHD. After careful evaluation, 70% of those young
children were found to have already had at least one additional psychiat
ric disorder in the year prior to enrollment in the study (Jensen et al. 2001).
A larger study involving 61,000 children ages 6–17 years found that
the 8.2% of children who had ADHD had much higher rates for other
disorders than did children who did not have ADHD (Table 7–1).
Among the children in the ADHD group, 33% had at least one addi
tional psychiatric or learning disorder, 16% had two, and 18% had three
or more (Larson et al. 2011).
The National Comorbidity Survey Replication found that of adults
ages 18–44 years who had not been referred for treatment, those with
ADHD were far more likely to have at least one additional psychiatric
disorder at some point in their life (Kessler et al. 2005, 2006). Table 7–2
shows the lifetime prevalence of other disorders in this sample and the
101
TABLE 7–1. Psychiatric disorders diagnosed in children with

and without attention-deficit/hyperactivity
disorder (ADHD)
ADHD (%) Non-ADHD (%)
Learning disability 46.1 5.3

Conduct disorder 27.4 1.8
Anxiety 17.8 2.1
Depression 13.9 1.4
Autism spectrum disorder 6.0 0.6
Source. Adapted from Larson et al. 2011.
odds ratio for each disorder. An odds ratio of 1.0 indicates that preva
lence of the disorder is the same for persons with ADHD as for persons
of the same age in the general population; 3.0 indicates three times the
base rate of persons of the same age in the general population.
Data from these three studies (Collaborative Multisite Multimodal
Treatment Study of Children With Attention-Deficit/Hyperactivity Disor
der, National Survey of Children’s Health, and National Comorbidity Sur
vey Replication) highlight the fact that children and adults with ADHD
tend to have significantly more learning or psychiatric disorders than those
without ADHD. This raises an important question: Why is it that children
and adults with ADHD are so much more likely to have multiple learning
or psychiatric problems? Are they just especially unlucky?
One possible explanation for the high rates of co-occurring disorders
associated with ADHD is that ADHD is not just one more among other
psychiatric disorders. It is a foundational disorder in that executive
function impairments of ADHD also underlie many other disorders.
Neuroscientist Joaquin Fuster (2003) emphasizes the critical role of at
tention, broadly defined, for all aspects of cognitive activity:
Perception is part of the acquisition and retrieval of memory; memory

stores information required by perception; language and memory depend
on each other; language and logical reasoning are special forms of cognitive
action; attention serves all the other functions. (p. 16, emphasis added)
Fuster (2003) describes the term attention as a system of higher neu

ral networks that manage and integrate other neural networks. He
speaks of attention networks as activating, inhibiting, and prioritizing
neural networks that control perception, thought, and action. He refers
How and Why Other Disorders Often Co-occur With ADHD 103
TABLE 7–2. Lifetime prevalence and odds ratio for psychiatric

disorders in persons with attention-deficit/
hyperactivity disorder
Lifetime prevalence (%) Odds ratio
Mood disorders 38.3 5.0

Anxiety disorders 47.1 3.7
Substance use disorders 15.2 3.0
Impulse disorders 19.6 3.7
Source. Data from Kessler et al. 2006.
to attention networks as crucial for regulating arousal and activation,

for selecting what stimuli will be attended to, and for integrating feed
back from bottom-up and top-down control of motivations. He also de
scribes working memory as an aspect of the attention system. His view
of attention is very broad and incorporates essentially the same cogni
tive functions included in the six-cluster model of executive functions
presented in Chapter 2, “A New Model of ADHD.”
Fuster’s point may be illustrated with an analogy: If the PowerPoint
software on your computer malfunctions, it is likely to cause difficulty
with your making and using slides, but it is not likely to impair your Ex
cel, Word, or other software programs. However, if the Windows oper
ating system of your computer is disrupted, that is likely to disrupt the
functioning of many, if not all, of the software programs on your com
puter. Similarly, impairments of ADHD may disrupt multiple cognitive
functions, some of which may be involved in disorders other than
ADHD. Directly and indirectly, ADHD-related impairments tend to
have broad impact on many aspects of cognitive functioning, which
may contribute to multiple impairments of other learning or psychiatric
disorders. In the following sections, I describe ways in which executive
function impairments of ADHD may contribute to various disorders
that often co-occur with ADHD.
Specific Learning Disorder

How Is ADHD Related to Specific Learning
Disorder?
Specific learning disorder is defined by DSM-5 (American Psychiatric As
sociation 2013) as “characterized by persistent and impairing difficulties
with learning foundational academic skills in reading, writing, and/or

math” (p. 32). Learning disorders are very common among individuals
with ADHD. A large clinical study of children ages 6–16 years diagnosed
with ADHD found that 76% met diagnostic criteria for one or more iden
tified learning disorders (Mayes and Calhoun 2007). The most frequent
learning disorder in this group of 678 children was disorder of written
expression (65%); frequency of reading disorder was 32%, and the rate
for mathematics disorder was 30%. These percentages are for those who
met diagnostic criteria for a specified learning disorder; many of the
other children in the sample had significant chronic difficulties with one
or more aspects of learning but did not meet full criteria for diagnosis of
a specified learning disorder.
For many years, learning disorders such as reading disorder (dys
lexia), mathematics disorder (dyscalculia), and disorder of written lan
guage were considered completely separate from ADHD. More recent
research has found that, although there are certainly differences be
tween learning disorders and ADHD, impairments of executive func
tions associated with ADHD are closely related to the impairments of
learning disorders. Many persons with learning disorders also have the
impairments of executive functions of ADHD, even though some clini
cians still do not notice those connections.
There was a time when most educators and psychologists consid
ered dyslexia to be essentially a problem of being able to recognize and
remember which combinations of letters make which particular sounds.
Teaching students phonics or other systems of skills to decode words
was seen as the key to helping students with dyslexia to read and un
derstand what they were reading. This view was challenged in 2008 by
dyslexia specialists Sally and Bennett Shaywitz, who argued that read
ing is not simply a modular process depending solely on being able to
decode words; it also involves attention mechanisms that are essential
to fluency and automaticity, the ability to read fluently.
Thus, the critical requirement for automaticity is for the reader to encode
the relevant items in memory and to retrieve them on a subsequent en
counter, and for both encoding and retrieval, attention is central. (Shay
witz and Shaywitz 2008, p. 1332)
How Are Executive Function Impairments

Related to Specific Learning Disorder?
More recently, other specialists in learning disorders have recognized
the critical importance of attention, working memory, and processing
speed in reading fluency and comprehension. These executive functions
are not so important for decoding and pronouncing single words, but
they are critical for comprehension of sentences and paragraphs. This
was described by Sesma and colleagues (2009):
Reading comprehension is inherently more complex than single word

reading. . . . [E]xecutive control skills such as planning and working
memory become more necessary as the length and complexity of written
text increases. (p. 8)
Comprehension of more complex text requires the ability to keep in

mind the main ideas or information presented in the text, both within
individual paragraphs and in the text as a whole. While reading, one
continually needs to update understanding of connections between
these elements to build and revise one’s mental pictures of information,
ideas, or actions generated by what is being read. Research has shown
that persons with ADHD tend to have more difficulty with these pro
cesses than do those without ADHD (Miller et al. 2013), probably be
cause of the working memory impairments that are common in ADHD
(Carretti et al. 2009).
Executive functions are also important in math. One study of first
and second-grade students found that those students who had low
achievement scores in math tended also to have more difficulties in
working memory. Researchers found that the scores of those children on
tests of working memory were better predictors of achievement in math
problem solving than were their scores for mastery of basic math skills
(Alloway et al. 2010; Toll et al. 2011). This makes sense if one considers
the importance of working memory for keeping track of the correct se
quence of operations and also for holding in mind when one has bor
rowed or carried over numbers from one column to another.
Executive functions are also strongly associated with disorder of
written expression. Our group at Yale compared scores on individually
administered achievement tests given to 145 adolescents with ADHD
ages 13–25 years; we found that for 70% of that group, their scores on
written expression were their lowest scores, significantly below their
scores for reading and for math (Brown et al. 2010). A large study that
compared children with and without ADHD found that 46.9% of those
with ADHD suffered from disorder of written expression, whereas only
9.6% of those without ADHD manifested that learning disorder (Yoshi
masu et al. 2011).
It is not surprising that individuals with ADHD struggle more with
written expression than with reading or math. Written expression places
much greater demands on executive functions than do reading or solv
ing math problems. When reading, one begins with words already in
sentences; when doing math, one starts with a stated problem. How
ever, when translating thoughts into sentences and paragraphs on a
blank screen or piece of paper, we must focus in order to plan and orga
nize our thoughts in coherent sequences, deciding what to say first, se
lecting appropriate words and images, and deciding how much to
elaborate and what to delete so we say enough to communicate each
thought and not so much that the writing is boring or redundant. We
need to maintain connections within each paragraph while also keeping
in mind links with what we have written in preceding paragraphs and
also what will follow. Then, we need to review and revise to clarify and
shape our intended message. All of these functions require integrated
operation of our executive functions.
Another aspect of executive functions essential to reading, mathe
matics, and written expression is activation—alertness and motivation
to perform the tasks. If a person is not motivated to read a text or to try
to solve a math problem or to write sentences and paragraphs, those
tasks are not likely to be adequately done, even if the person has the req
uisite skills. A study of junior high students who were asked to read so
cial studies texts found that the importance a student attributes to
reading a particular text is a more important determinant of whether or
not the student will comprehend a text than is the individual’s cognitive
capacity to read well.
[C]omprehension of challenging text seems to require not only cogni

tion, but also motivation...beliefs about how important it is to do well
on given tasks, how useful those tasks are in relationship to current and
future goals, and how intrinsically interesting they are to the individual.
(Anmarkrud and Braten 2009, p. 252)
These findings are quite consistent with the description of situa

tional variability of ADHD symptoms provided in Chapter 1 (“Basic
Facts and the Central Mystery of ADHD”). A specific example of the im
pact of motivation on reading was provided by a college student with
ADHD, who observed,
If I’m reading some text that doesn’t really interest me, it’s as though I’m
just licking the words and not chewing them. My eyes go over each
word and I understand what all of it means as I’m reading it, but I’m just
not engaged enough to get the information to stick inside my head.
(Brown 2013, p. 140)
Data and examples in this section have highlighted various ways

that executive function impairments of ADHD can contribute to learn
ing disorders such as reading disorder, mathematics disorder, and dis

order of written expression. Yet it is important to keep in mind a
dimensional view of these functions. Although many individuals with
ADHD have sufficient impairment to warrant diagnosis of a specific
learning disorder in reading, writing, or written expression, many oth
ers with ADHD who do not qualify for a diagnosis of a specific learning
disorder are impaired in their ability to read with comprehension, to
work effectively in solving math problems, and/or to give written ex
pression to their thoughts. Executive functions impaired in ADHD can
cause difficulties in one or several of these skills in ways that are signif
icant, even if they are not sufficiently severe to warrant a diagnosis of
specific learning disorder.
Anxiety Disorders
How Is ADHD Related to Anxiety Disorders?
Anxiety disorders are much more common among children and adults
with ADHD than in the general population. In samples of children with
ADHD, the incidence of anxiety disorders ranges from 9.6% to 34% (Jen
sen et al. 2001; Yoshimasu et al. 2012). Among adults with ADHD, rates
range from 27.9% to 47.1% (Kessler et al. 2005; Van Ameringen et al.
2011). A meta-analysis found that across multiple studies, the average
rate of anxiety disorders in children with ADHD was three times the
rate among children in the general population. A nationwide study of
adults with ADHD found the rate of anxiety to be 3.7 times as high as
among the general population of adults in the United States.
Anxiety disorders come in many different forms. Some individuals
have just one anxiety disorder, whereas others are burdened by several
types of anxiety disorders. Many children and some adults have phobic
fears. For example, they may get very tense, worried, and upset when they
get near to or expect very soon to get too close to a dog. Suddenly, their
heart beats a lot faster, they imagine themselves being attacked by the
dog, they feel panicky, and they want to get away from the dog as quickly
as possible. They then want to continue to avoid that dog and, perhaps,
any other dog. As soon as they can avoid the dog and safely stay away
from it, the fear usually diminishes quickly. Other examples of phobia in
clude intense fear of snakes, bees, thunder and lightning, being in high
places, getting an injection, seeing blood, or flying in an airplane.
Many children and some adults have one or more such fears that are
stronger, more persistent, and more problematic than is usual for their
peers. Usually, fears are not diagnosed as phobic unless they are mark
edly more intense, more frequent, and significantly out of proportion to
any actual danger posed by the specific object or situation.
Social anxiety is a type of phobia in which a person is almost always in
tensely fearful of getting into social situations with others whom they do
not already know and trust. They worry that other people will see them
as unappealing, boring, ridiculous, incompetent, socially awkward, ugly,
immature, offensive, stupid, or in some other way not fitting in with oth
ers in the situation. To warrant diagnosis, this anxiety must be way out of
proportion to any realistic threat in the situation. For children, this diag
nosis is fitting only if the social anxiety occurs not only with adults but
also with peers.
Sometimes social phobia appears only when the person enters into
an unfamiliar group or situation where he or she will be expected to in
teract with others. For others with social phobia, their fear is just as in
tense even if they are simply eating in a restaurant or doing some other
activity among strangers where they may be observed or expect to be
noticed by others.
The primary way that those with social phobia usually try to avoid
feeling too anxious is to stay away from unfamiliar situations where they
believe they are likely to have to interact or to be observed in a negative
way. Often, their fear is not only that they will be overtly treated in a neg
ative way; they are often intensely intimidated by what they assume oth
ers are thinking about them, even if other people are not speaking to or
even actively noticing the worried person. Typically, the social anxiety
does not occur when the person is with family or others whom he or she
knows well and trusts to not be exaggeratedly critical or rejecting.
Another type of anxiety disorder is panic disorder: brief but recurrent
episodes of sudden, overwhelming fear. Typically, a panic attack in
volves sudden onset of dizziness, sweating, trembling, shortness of
breath, chest pain, and rapid heart rate, sometimes with pounding heart
sensations that cause the person to feel that he or she is suffering a heart
attack and is about to die. For some people, these terrifying sensations
come without any warning and are not associated with a known fear;
they usually subside within 10 or 15 minutes. For others, a panic attack
may be expected to occur because they are approaching a setting or sit
uation in which a panic attack has been experienced previously. Panic
attacks may occur once or twice a week for months at a time, or they
may be experienced in frequent batches (e.g., once or more often every
day for a week or two) and then not for many months. Often, the most
problematic aspect of panic disorder is the individual’s worrying in
tensely about when and where another panic attack might occur.
For some individuals, panic disorder is associated with agoraphobia,

an intense and persistent fear of leaving one’s home or usual “comfort
zone” without being accompanied by a trusted person. This anxiety dis
order is often persistent and chronic; it is very difficult to treat.
One additional type of anxiety disorder is generalized anxiety disorder,
which involves a persistent pattern of excessive, uncontrollable worry
and anxiety about many possible events or activities. Primary symp
toms include protracted periods of subjective distress and feeling keyed
up, restlessness with inability to relax, chronic muscle tension, difficulty
concentrating, being fatigued easily, chronic irritability, and difficulty
falling asleep or staying asleep. Often, persons with generalized anxiety
also experience physical symptoms of stress such as chronic headaches,
migraines, psoriasis, reflux, nausea, diarrhea, or irritable bowel syn
drome.

Related to Anxiety Disorders?
There are significant differences between ADHD and the various anxi
ety disorders, but some or many executive function impairments may
also play a significant role in anxiety disorders. Research has found that
attentional bias to possible threat plays an important role in many types
of anxiety disorder. The term attentional bias refers to the tendency of an
individual to be consistently hyperalert to any perceptions that might
suggest a potential threat of physical or social/emotional danger. Not
only are individuals alert to such signs, they tend to seek out and focus
on such potential threats in ways that magnify their worry about the
perceived threat, while ignoring other potentially relevant information
(Shechner et al. 2012). Anxious individuals tend to be biased in their in
formation processing at several levels: in what they focus their attention
on (orienting), in how they size up situations they encounter in terms of
likely impact on them (appraisal), and in what patterns of response they
have found helpful for them (learning and behaviors) (Britton et al.
2011). As a result of this bias, they tend to have considerable difficulty in
shifting their focus to attend to the larger context of what they perceive.
These patterns can become self-reinforcing.
Attentional bias toward possible threats is especially common in
boys and girls who in infancy are exaggeratedly fearful of novelty and
who in early childhood tend to be excessively shy and overly cautious
(Kagan 2010). Longitudinal studies have shown that attentional bias in
such children tends to persist into young adulthood and is associated
with patterns of connectivity in brain circuits that intensify anxious re
actions to various stimuli (Hardee et al. 2013). Neural circuits of their
brains seem to become “wired” to have hair-trigger responses to any po

tential threat. This can cause these individuals to develop chronic stress
and a behavioral tendency to be consistently overly cautious and exces
sively guarded.
Another aspect of executive functions that plays an important role in
anxiety disorders is working memory. Numerous studies have demon
strated that persons with stronger working memory capacity tend to
have stronger ability to regulate their emotional responses, minimizing
excessively strong emotional responses (Schmeichel et al. 2008). Weak
ness of working memory is one of the primary impairments associated
with ADHD (Alderson et al. 2013; Fried et al. 2016; Kennedy et al. 2016;
Martinussen et al. 2005). Because stronger working memory is associ
ated with greater ability to modulate emotional responses, it is not sur
prising that many persons with ADHD also have significant difficulty in
modulating their anxiety. They are more likely to have difficulty keeping
in mind additional relevant information that may, for others, reduce the
tendency to overreact to potential physical or social/emotional threats.
Depressive Disorders
How Is ADHD Related to Depressive Disorders?
Children and adults with ADHD have considerably greater likelihood
of having a depressive disorder sometime in their lifetime than do per
sons without ADHD. Rates for depression in children with ADHD
range from 9.6% to 34%, much higher than the 1.4%–7.2% in the general
population of children. A meta-analysis of 21 epidemiological studies
found that the odds of a youth diagnosed with ADHD also being diag
nosed with depression are more than fivefold higher than for youth
without ADHD (Angold et al. 1999).
The importance of depression in children with ADHD is highlighted
by research that demonstrated that children with ADHD and comorbid
mood disorders are three times more likely to complete suicide than
those diagnosed with either ADHD or mood disorder alone (James et al.
2004). Rate of depression for adults with ADHD is approximately 31%,
considerably above the 17% rate for adults in the general population
(Kessler et al. 2006).
One of the two major types of depression is persistent depressive dis
order (formerly dysthymia). This diagnosis is not usually made unless the
person has suffered from this syndrome for at least 2 years (1 year for
children or adolescents). One of my young adult patients described his
experience with persistent depressive disorder as follows:
For the past couple of years, I’ve been walking around feeling bummed
out. I can still keep doing most of what I need to do each day, like getting
to work and picking up groceries once in a while. But I almost never enjoy
any of it, including things I really used to enjoy doing, like seeing my
friends and going out. I don’t have much energy, and I tend to get down
on myself quite a bit. Occasionally, something interesting will happen
and I can get into that for a while, but as soon as the interesting part is
over, I go right back to that same dark feeling: “Everything sucks, every
thing always sucks, everything always will suck. That’s just the way it is.”
The other primary type of depression is major depressive disorder. This

is similar to persistent depressive disorder, but it is much more intense
and more immobilizing and involves more disruption of eating and
sleeping. Often, it also involves preoccupation with thoughts of death
and the possibility of suicide. One patient with this disorder reported,
It’s been nearly 2 months now, and almost every day I feel completely
hopeless. Often, I feel dead tired but just can’t get to sleep, or I fall asleep
for a few hours and then I’m wide awake and can’t get back to sleep even
though it’s the middle of the night. There have been a few times when
I’ve stayed in bed for a couple of days, half sleeping or half awake, just
getting up once in a while to get a drink of water or use the bathroom,
not able to get myself to go to work or do anything productive. I don’t
feel like talking with anybody and I don’t feel like eating much of any
thing. When I’m awake, I just keep thinking about how much of a hope
less failure I’ve always been and how everyone would probably be
better off if I weren’t around anymore.
Episodes of major depressive disorder may last for just a few months
or for a year or more. Some people have just one such episode in their
lifetime. Others may have recurrent episodes of major depression inter
spersed with periods of no depression. Still others suffer from persistent
depressive disorder for much of their life, with episodes of major de
pression occurring from time to time.

Related to Depressive Disorders?
Although current diagnostic criteria for ADHD include no symptoms of
problems with emotions, research on persons with ADHD suggests that
problems with regulation of emotion are an important aspect of execu
tive function impairments. Clinical data from various samples and the
oretical arguments described by Barkley (2010) and Brown (2005a, 2014)
suggest that problems in emotional regulation constitute a significant
aspect of the core problems of persons with ADHD. A review paper by
Shaw et al. (2014) summarized research relevant to this issue.
Data from normed rating scales used to identify persons with

ADHD also support the importance of emotional regulation in those
with ADHD. Conners’ Adult ADHD Rating Scales (Conners et al. 1999)
include two items related to anger regulation (“still throw tantrums,”
“short-fuse, hot temper”) and two items related to depression (“lack
faith in my abilities,” “hard to believe in myself”) in the ADHD index
that comprises the 12 statistically best items for identifying adults with
ADHD. Data from the Brown ADD Scales for Adolescents and Adults
(Brown 1996) indicate positive correlations between responses to items
related to emotional regulation (“excessively impatient,” “sensitive to
criticism,” “easily irritated,” “depressed mood”) and the total score for
all five clusters of impairments of executive functions.
Several studies have shown that problems in emotional regulation
are a primary factor underlying depression in youth, both in the general
population of children and adolescents and in samples of youth with
ADHD (Durbin and Shafir 2008; Feng et al. 2009; Melnick and Hinshaw
2000; Walcott and Landau 2004). One recent study demonstrated that
the relationship between ADHD and depressive symptoms in youth is
not just partially but is fully mediated by impairments in emotional reg
ulation typically found in those with ADHD (Seymour et al. 2012).
Research mentioned in the section “How Are Executive Function
Impairments Related to Anxiety Disorders?” about the relationship be
tween ADHD working memory impairments and elevated rates of anx
iety in persons with ADHD is also relevant to the elevated rates of
depression in those with ADHD. Research by Schmeichel et al. (2008) in
cluded the hypothesis that persons with stronger working memory are
better able to regulate their reactions to depressive feelings as well as to
feelings of anxiety. Impairments of working memory characteristic of
most persons with ADHD are likely to be a significant factor in their rel
ative weakness in regulating both types of emotion. The mechanism of
this is actually quite simple. If a person is relatively weak in his or her
ability to keep multiple bits of information in mind at the same time
(weak working memory) when confronted with situations that trigger
anxious and/or depressive emotions, that person is likely to get more
intensively engaged with those negative emotions than is someone who
is better able to keep in mind other information (stronger working mem
ory) that may be less negative (e.g., possible ways of coping effectively
with the negative situation or more positive bits of information that pro
vide more reason to hope for a less negative outcome).
Evidence of memory impairments in depression was provided by
recent research that compared functional magnetic resonance imaging
(fMRI) studies of adults with and without current or remitted depres
sion (Young et al. 2016). Findings showed that both those currently de
pressed and those who were depressed but whose depression had
remitted demonstrated less activation of the amygdala and related cir
cuits when recalling positive memories from their life and greater brain
activation when recalling negative autobiographical memories. Their
brain activity was significantly biased for recall of negative experiences
of the past. The recall bias problem demonstrated in these patients with
depression but not ADHD is likely to be even stronger in those with
ADHD who experience depression or have experienced depression,
given the weakness of working memory usually found in those with
ADHD.
Another perspective on the linkages between depression and ADHD is
provided by data from genetic studies. A major study of genetic linkages
between psychiatric disorders found significant moderate correlation
between ADHD and major depressive disorder based on genome-wide
single-nucleotide polymorphism data (Lee et al. 2013).
Bipolar Disorders
How Is ADHD Related to Bipolar Disorders?
For many years, the diagnosis of bipolar disorder was classified with
depressive disorders as though they were all just variations of the same
processes. More recent research has highlighted differences that make it
important to conceptualize depression and bipolar disorder as two sep
arate categories of significant problems with mood. Although incidence
rates of bipolar disorder in the general population are quite low, about
3.9% in adults (Kessler et al. 2005), those with this disorder have ex
tremely high rates of substance use disorders and premature death due
to suicide and associated medical conditions, as well as substantial role
impairments, e.g., ability to work, and elevated rates of hospitalization.
When the full spectrum of bipolar syndromes, including subthreshold
cases, is considered, incidence in the general population increases to al
most 6% (Merikangas et al. 2007).
Reported rates of bipolar disorder among adults diagnosed with
ADHD are about 17% (Millstein et al. 1997). Among children with
ADHD, estimated incidence of bipolar disorder ranges from 2.4% to
21%; the wide differences in those rates depend on whether or not re
searchers required that bipolar symptoms occurred in episodes, as stip
ulated by DSM-IV (American Psychiatric Association 1994). Including
those who tend to have consistently irritable mood without episodes of
nonagitated, euthymic mood inflates the estimated incidence of bipolar
disorder. DSM-5 introduced the new diagnostic category disruptive

mood regulation disorder to describe individuals with more consistent,
nonepisodic mood problems, but in DSM-5, this new type of mood
problem is classified with depressive disorders rather than with other
mood disorders.
There are two main types of bipolar disorder. Bipolar I disorder is
characterized by one or more episodes in which the person’s mood sud
denly switches from being normal or depressed to a manic episode: per
sistently feeling and acting abnormally elevated, expansive, or irritable
most of the day, almost every day, for at least 1 week. Often, patients
with bipolar I disorder require at least brief psychiatric hospitalization.
Elevated mood may involve markedly heightened energy and feel
ing high, with exaggerated enthusiasm for interpersonal interactions
(e.g., calling old friends in the middle of the night to rekindle friendship,
attempting inappropriate sexual encounters). Expansive mood often in
volves grandiose plans or unrealistic claims of having extraordinary im
portance, abilities, or powers. These high moods may suddenly shift to
unusually intense anger or irritable actions that are verbally or physi
cally aggressive; often, these occur in response to situations in which the
individual’s wishes are challenged or frustrated.
Typically, persons in a manic state feel little need for sleep and may
work, party, or engage in multiple new projects throughout the day and
night, not wanting to take time to sleep. They may continually be phys
ically restless, unable to sit still. Their speech may flow much more rap
idly than usual, while their thoughts and conversation repeatedly jump
from one focus to another in ways that may be difficult to follow. During
a manic period, persons who are usually thoughtful and quite reason
able may plan or begin to act in ways that show impaired judgment and
are likely to cause them to suffer painful consequences (e.g., purchasing
many items they do not need and cannot afford, suddenly quitting a job
or ending a relationship in ways that may be very costly to them and
subsequently cause much regret). Often, during a manic episode, the
person does not recognize that he or she is mentally ill. The risk of sui
cide in persons with bipolar I disorder is 15 times greater than in the
general population (American Psychiatric Association 2013).
Bipolar II disorder is a diagnosis used to describe persons who have
suffered one or more episodes of hypomania and at least one major de
pressive episode, which may occur shortly before or soon after the hy
pomanic episode. Manic symptoms in hypomania are quite similar to
those of mania in bipolar I disorder, but they tend to be more short-lived
and more impulsive and do not generally require psychiatric hospital
ization.

Related to Bipolar Disorders?
The most obvious way in which bipolar disorder reflects executive func
tion impairment is heightened difficulty in managing emotions (Pataki
and Carlson 2013). Often, manic episodes are characterized by marked
intensification of irritability, anger, or exaggerated enthusiasm at levels
quite uncharacteristic of the individual’s usual pattern of behavior:
emotional expressions without adequate self-control.
Overlap between ADHD and bipolar disorder also involves two ad
ditional clusters of executive functions often impaired in persons with
ADHD: 1) ability to monitor and self-regulate action and 2) ability to
self-regulate levels of arousal and processing speed. During episodes of
mania, the person often gets caught up in intense, driven behaviors not
modulated by the usual levels of self-control. This may involve inces
sant rapid speech, inability to relax or sit still, or determination to pro
ceed with actions that are impulsive and ill-considered. In addition,
manic episodes often include loss of ability to regulate sleep and alert
ness; usual patterns of sleep are lost, and often the person feels no need
to sleep for several days until the manic episode abates, at which time
the person may collapse into lengthy episodes of long-overdue sleep.
Oppositional Defiant Disorder

and Conduct Disorder
How Is ADHD Related to Oppositional Defiant
and Conduct Disorders?
Oppositional defiant disorder (ODD) and conduct disorder (CD) have long
been seen as closely related to the combined (more hyperactive) type of
ADHD. Oppositional defiant disorder is defined in DSM-5 as a recurrent pat
tern of angry/irritable mood, argumentative/defiant behavior, and/or
vindictiveness that is significantly more extreme than usual patterns in the
age group, tends to occur at least once a week, and lasts at least 6 months. In
the general population of the United States, ODD has been found to occur
in about 10%–12% of children (Merikangas et al. 2010; Nock et al. 2007).
Among children with ADHD, the estimated prevalence of ODD ranges
from about 15% to 50%, with the higher prevalence among those with
the combined type of ADHD (Connor et al. 2010).
ODD usually has onset at about age 12 years, but this pattern of se
vere, chronic oppositionality and irritability sometimes appears earlier,
even in preschoolers who greatly exceed the range of such behavior

seen in most of their peers (Burke et al. 2010). Usually, this pattern per
sists for about 6 years and gradually remits. Most children and adoles
cents diagnosed with ODD (70%) do not develop CD, a much more
severe pattern of behavior problems. However, over the longer term,
some with ODD suffer from elevated rates of school suspensions, and
some develop major depressive disorders (Biederman et al. 2008).
Conduct disorder is defined in DSM-5 as “a repetitive and persistent
pattern of behavior in which the basic rights of others or major age
appropriate societal norms or rules are violated” (American Psychiatric
Association 2013, p. 469). These violations may involve threatening or
causing physical harm to persons or animals; aggressive behavior that
causes loss or damage to property; deceitfulness or theft; and serious vi
olations of parental, school, or workplace rules. DSM-5 reports preva
lence estimates of CD range from about 2% to more than 10% of the
general population, with a median of about 4%. Often, those who de
velop CD have previously had ADHD, but less than 30% of those with
ADHD and ODD develop symptoms of CD sufficient to warrant diag
nosis.

Related to Oppositional Defiant
and Conduct Disorders?
At first glance, ODD might be considered simply another example of
the executive function not modulating emotions, similar to anxiety and
depressive disorders. However, both ODD and CD also involve prob
lems in modulation of both emotional expression and inhibition of some
types of passive or overt aggressive behavior.
ODD usually includes recurrent patterns of failure to inhibit actions,
such as defiant verbal outbursts and overt actions, or failure to act. This
causes considerable trouble for individuals with ODD and for their par
ents, teachers, and other caretakers. In those with CD, defiance of au
thorities and social expectations may be less weighted with emotions,
more cold and emotionless, but the actions of individuals with CD are
much more severe than the actions of those with ODD and are likely to
carry heavier penalties; the failures of inhibition of action are more de
structive and may be more dangerous to self and others. Another im
portant characteristic of individuals with ODD or CD is that they tend to
be quite impulsive in their actions. Often, they do not hesitate long
enough to consider the longer-term impact of swearing at their teacher,
shouting rudely at their boss, shoplifting an article they want in a store,
or driving a car at excessive speed. Their working memory does not

bring up in the moment adequate anticipation and planning for poten
tial consequences; they do not ask themselves, “What is likely to happen
if I do this?”—they just do it. This is another example of the problem
mentioned in Chapter 5, “How ADHD Impacts ‘Brain Googling’ for
Motivations”: persons with ADHD often get so focused on their imme
diate situation that they lose sight of the larger context, much as some
one observing a basketball game through a telescope may get a good
look at a very limited aspect of the action while not being able to see op
portunities or threats in the actions on the rest of the court. Keeping the
context and possible consequences in mind is an important aspect of the
executive function cluster of monitoring and self-regulating action.
Obsessive-Compulsive
and Related Disorders
How Is ADHD Related to Obsessive-Compulsive
and Related Disorders?
Obsessive-compulsive and related disorders are a grouping of disorders that
involve either or both of two aspects: 1) recurrent thoughts, images, or
urges that persist, even though the individual wishes to avoid or forget
them, and 2) repetitive behaviors or mental actions that the person feels
driven to do and that result in anxiety if the behavior is not done, even
though the person may recognize that these actions do not make much
sense or provide much realistic benefit.
Prevalence of obsessive-compulsive disorder is reported to be about
2%–4% in the general population of children and adolescents; preva
lence in adults is about 1.5%–3% in the general population. Among chil
dren and adolescents diagnosed with ADHD, the incidence ranges from
6% to 33% (Geller and Brown 2009; Storch et al. 2008). There is great va
riety in the way obsessive-compulsive and related disorders present; a
few examples are provided below.
Case Example: A religious child who refuses

to attend church
A very religious 15-year-old boy willingly attended church with his very
religious parents every Sunday. Over several weeks, he became increas
ingly reluctant to go to church; on the fourth consecutive Sunday, he
completely refused to go to church and cried inconsolably, claiming he
wanted to go but did not know why he could not. He said he just could
not do it and probably never would ever attend church again. In psycho
therapy, he disclosed that about 6 weeks earlier, while in church, he had
the thought “What would happen if I stood up during this quiet prayer
time and said ‘Fuck you!’ out loud?” He thought of how embarrassing it
would be for him and his parents. He told himself that he would never
actually do such a thing, but he kept thinking about it every day and
could not get it out of his mind. Every Sunday for the next month he
struggled in church, terrified that he would suddenly lose control, get
up and do it. Finally, to avoid the risk, he stubbornly refused to go to
church, although he felt unable to explain his reason to his parents.
This boy’s sudden refusal to attend church services was the result of
his being terrified of his unacceptable urge to embarrass himself in a
public place. He was puzzled and frightened by this persisting thought,
terrified that he might act on it. Gradually, in psychotherapy it became
clear that this was related to his feeling increasing guilty about mastur
bating to erotic fantasies.
Case Example: A young mother who fears
hurting her baby
A 31-year-old mother felt overwhelmed and a bit resentful about the

hard work of caring for her first infant. She became preoccupied for
months with the persistent thought that she might accidentally put a
poisonous substance in her infant’s bottle; she became unable to get out
of her head the image of her baby dying in her arms as a result of her
carelessness.
Case Example: A woman distressed about her

husband’s safety
A 26-year-old woman, recently married, worried excessively when her hus
band did not return by exactly the time she expected him. If he did not ar
rive by that time, she felt compelled to stand by the window to watch for
him as she imagined various reasons he might be late. As the minutes ticked
by, she was able to stay relatively calm as long as she kept staring out the
window awaiting his arrival. If she walked away from the window, even
briefly, her mind filled with images of her husband having been injured in a
motor vehicle accident, being taken to the hospital in an ambulance, dying,
and lying in a casket. For her, standing by the window to await him was her
only protection from being overwhelmed by morbid thoughts.
Case Example: A driver who fears injuring
a pedestrian
A 42-year-old man worried that while driving, he might accidentally

run over a pedestrian waiting to cross the street and not even notice that
it had happened. Each time he drove through an intersection where pe
destrians were waiting at the curbside to cross, he had to check his rear
view mirror to make certain that there was no pedestrian lying injured in
the crosswalk. If he could not see that all were safe, he felt compelled to
drive around the block and drive once again through that intersection to
verify that he had not injured anyone.
Another way in which obsessive-compulsive disorder commonly

manifests is excessive perfectionism that extends far beyond any rea
sonable assessment of what constitutes doing a good job on a task. Some
patients report that when taking notes in a class or a meeting, if they ac
cidentally write outside page margins or misspell a word, they cannot
simply erase or cross out the mistake; they feel a strong urge to discard
the entire page and attempt to completely rewrite what they had on the
page so it will appear perfect.
Others have similar difficulties when they are writing an e-mail, a re
port, an essay, or a term paper. They are unable to write a first draft, re
view it to correct errors, and then send it on. They feel an irresistible
pressure within themselves to get the first sentence written so it will
sound “just right” before they can allow themselves to write the second
sentence. They then need to write and rewrite that second sentence until
it sounds just right to them; they cannot begin the third sentence until
the second sentence has been perfected. They try to follow the same pro
cedure through to the completion of the paper and continue to rewrite
each sentence until it meets that requirement of perfection. This very
slow and tedious way of attempting sequential perfectionism in writing
proceeds from sentence to sentence, greatly delaying completion of the
task and often preventing the task from being completed at all. For
some, this excessive perfectionism is limited specifically to tasks of writ
ten expression. For others, such rigidity is just one of many manifesta
tions of an obsessive-compulsive personality disorder.
These examples illustrate just a few of the wide variety of ways in
which obsessive-compulsive disorder can impair the functioning of
children and/or adults. Related disorders include body dysmorphic dis
order, the inordinate preoccupation with perceived defects or flaws in
one’s physical appearance not observable to others; hoarding disorder,
the excessive and persistent impulse of an individual to save various ob
jects and to become very distressed at the prospect of losing even objects
that are totally useless and of no apparent value, even when these ob
jects clutter living space so much that it cannot be adequately used;
compulsive pulling out of individual hairs (trichotillomania); and pick
ing compulsively at one’s skin with such persistence that it results in
chronic bald patches or sores (excoriation disorder).

Related to Obsessive-Compulsive
and Related Disorders?
One executive function impairment that characterizes many types of
obsessive-compulsive disorder is chronic difficulty in inhibiting one ac
tion or behavior to shift to another (Chamberlain et al. 2005). Affected
persons have difficulty shifting between microfocus on one specific con
cern or aspect of a task or situation to a broader, more macro view. This
makes it difficult for them to realistically recognize how that one spe
cific task or situation fits into the larger context of that task and other
goals or concerns.
The boy who felt he had to avoid attending church focused so in
tently on his fear of impulsively shouting out during the church service
that he lost sight of how that fear of embarrassing himself and his family
would protect him from taking that action. He feared that the thought
would force the deed, losing sight of the difference between thinking
and doing. He concentrated on the fear while distracting himself from
his irrational guilt over the masturbatory behavior in which he contin
ued to engage.
Likewise, the young mother focused so intently on her fear of poi
soning her child that she distracted herself from her quite understand
able wish to be less weighted down by her increased burdens of caring
for him. She lost the distinction between wishing and doing as she
struggled to preserve her picture of herself as being totally happy about
being a mother, ignoring the reality of the accompanying frustrations.
She was not able to shift her attention to see the broader picture—a
weary new mother who loved her child but also felt some resentment
for the associated new responsibilities.
This same impairment of ability to shift focus, to inhibit and stop one ac
tivity to focus instead on another, is involved for those who are caught up in
excessive perfectionism in their writing. They become so focused on their
wish to do a very good job that they lose sight of how doing a good job fits
into the larger context of completing the task in a timely manner to meet a
deadline and to reserve ample time for other required tasks. Difficulty in
shifting focus and inhibiting one action to engage in another is connected to
another executive function: prioritizing. Determining which of multiple
tasks to do first, second, and third requires shifting focus from a single task
to a broader view that looks at the larger context of tasks and demands,
weighing one against the other in terms of both immediate and longer-term
goals. Similar problems in shifting focus and prioritizing characterize
hoarding difficulties; the individual is unable to keep the broader context in
mind and loses the ability to prioritize which objects are worth keeping and
which ones need to be released or discarded.
Substance Use Disorders

How Is ADHD Related to Substance
Use Disorders?
Substance use disorders differ from other disorders often accompany
ing ADHD because of the role of the substance and context of using it in
sustaining the disorder. Unlike other disorders such as anxiety disor
ders, depression, bipolar disorder, and obsessive-compulsive disorder,
substance use disorders are shaped primarily by the actions of a chem
ical substance introduced into the body deliberately to modify mood,
thought patterns, or social interactions. Usually, getting access to and
using these chemical agents also involves the individual in a social con
text that can have a significant negative effect on motivations, patterns
of behavior, and self-understanding. Interacting with the persons who
provide the substance and with others who use it can have a powerful
impact on the individual’s view of self and patterns of interacting with
family, friends, and classmates or coworkers.
Substance use disorders involve patterns of addiction. Drug addic
tion is a disorder, often, but not always, with chronic relapses, charac
terized by 1) compulsion to seek and take the drug, 2) loss of control in
limiting intake, and 3) emergence of a negative emotional state (e.g., de
pressed mood, anxiety, irritability) that reflects a motivational with
drawal syndrome when access to the drug is not available. Addicts do
not repeatedly seek to use the drug of abuse to gain pleasure; they ur
gently seek it to reduce their stress and pain.
Repeated episodes of excessive use of illicit drugs cause the brain’s re
ward system to gradually undergo physical changes that modify how the
brain reacts to such drugs. A landmark study reported that imaging stud
ies have provided evidence that these changes involve “reprogramming
of neuronal circuits that process (1) reward and motivation; (2) memory,
conditioning, and habituation; (3) executive function and inhibitory con
trol; (4) interoception and self-awareness; and (5) stress reactivity” (Koob
and Volkow 2010, pp. 225–226).
There is a lot of evidence that individuals with ADHD have a greater
risk of developing a substance use disorder at some point in life than do
persons without ADHD. This may be related to a common genetic network
that underlies both substance use disorders and ADHD (Arcos-Burgos et
al. 2012). Table 7–3 contains data from a meta-analysis of 27 studies in
volving more than 4,000 persons with ADHD and 6,000 persons without
ADHD assessed at an average age of 18.9 years. Numbers shown repre
sent pooled odds ratios in which 1.0 indicates no difference from the non-
ADHD sample and 2.0 indicates twice the likelihood of the non-ADHD
sample (Lee et al. 2011).
These data from multiple studies indicate that overall substance use
disorder is more than two and a half times as frequent among young
adults with ADHD than in the general population of similar age (Lee et
al. 2011). The negative impact of substance use disorders combined with
ADHD is substantial, particularly their impact on education. A massive
study of 29,000 adults in the United States found that failure to graduate
from high school by the usual age of 18 years was significantly more
common among persons with ADHD in combination with a substance
use disorder than among persons with any other psychiatric disorder
combined with substance use disorder (Breslau et al. 2011). Often sub
stance use disorders become sufficiently impairing that the individual
seeks treatment. A meta-analysis of 29 studies found that one out of ev
ery four patients seeking treatment for substance use disorder also had
ADHD (van Emmerik-van Oortmerssen et al. 2012).

Related to Substance Use Disorders?
The most important effect of executive function impairments on sub
stance use disorders appears to be through the impact of these impair
ments on the individual’s ability to function successfully in schooling.
Data from the large study of high school graduation rates mentioned in
the previous subsection indicated that
attention problems assessed at the time of school entry are associated with
lower academic achievement, as measured by standardized tests, at the end
of primary school...and at the end of high school....This increased burden
in students with ADHD to perform the tasks that underlie academic perfor
mance (i.e. working memory, processing speed, organization of informa
tion) may have cumulative negative effects. (Breslau et al. 2011, p. 299)
The point here is that when students who demonstrate significant

problems with attention (i.e., problems with executive functioning) start
school, they tend, as a group, to do relatively poorly from their earliest
school years through primary school and high school and tend to be
slower to complete high school or may not graduate from high school at
all. Breslau et al. (2011) also provided evidence that such school difficul
ties appear to be related to impairments of executive functions.
TABLE 7–3. Likelihood of substance use disorder in persons

with attention-deficit/hyperactivity disorder
(ADHD) versus persons without ADHD
Odds ratio
Nicotine 2.82
Alcohol 1.7
Marijuana 2.29
Cocaine 2.05
Overall substance use disorder 2.64
Note. Odds ratio of 1.0 indicates no difference between persons with ADHD and per
sons without ADHD; odds ratio of 2.0 indicates that persons with ADHD have twice
the likelihood of use.
Source. Data from Lee et al. 2011.
This route from executive function impairments of ADHD to school

problems to substance use disorder was demonstrated in findings of addi
tional research that prospectively studied children with ADHD and a com
parison sample from ages 13–18 years (Molina and Pelham 2003). Data
from that study showed that inattention symptoms of ADHD were better
predictors of later substance use disorders than were childhood antisocial
behaviors such as CD. Results from that study showed that ADHD in child
hood is as strong a predictor of substance abuse as having a positive family
history of substance use disorder. The researchers argued that
inattention may influence substance abuse through mediational vari

ables such as poor academic achievement and peer difficulties....[W]hat
may follow is gravitation away from conventional group values and be
haviors that include academic success, and gravitation toward noncon
formist peer groups where substance use is tolerated and modeled.
(Molina and Pelham 2003, p. 504)
Clinical experience supports this view that social context often plays
an important role in substance use disorders. Individuals who use
drugs of abuse excessively often withdraw from their previous social re
lationships and tend to spend more time with others with whom they
can join comfortably in more excessive drug use. This can provide com
panionship with others less likely to be judgmental of their drug use; it
may also provide connections where they can more easily procure
drugs not legally available to them.
For individuals, especially adolescents or young adults, trying to re

cover from excessive drug use, it can be very difficult to change their so
cial context. Those who have developed a reputation as a “heavy stoner”
or “druggie” may not be welcome to return to a former friendship group.
It may be very difficult for them to gain access to friends who are not ac
tively using drugs of abuse.
Sustaining recovery from drug abuse is extremely difficult if the re
covering addicts return to the social context in which they were previ
ously using, especially if former friends in that setting are still actively
using drugs. There is strong evidence that when individuals who have
been addicted to a substance return to the context in which they previ
ously practiced their addiction, even after a long period of abstinence,
multiple cues intensify brain activity that produces intensified craving
and a strong push toward seeking and resuming use of the habitual
drug (Crombag et al. 2010).
Another point of linkage between ADHD and substance use disor
ders has been identified by genetic studies. Results from the National
Human Genome Study included evidence that a common genetic net
work underlies substance use disorders and ADHD as well as ODD and
CD (Arcos-Burgos et al. 2012). Many of these genes are associated with
the development and guidance of the development of neural pathways
and regulation of synaptic transmission, among other functions.
Autism Spectrum Disorder

How Is ADHD Related to Asperger’s Disorder
and Autism Spectrum Disorder?
Over recent years, many studies have identified significant similarities
between ADHD and autism spectrum disorder (ASD) (Grzadzinski et
al. 2011; Martin et al. 2014; van der Meer et al. 2012). Grzadzinski and
colleagues (2011) evaluated parent ratings of 75 children ages 7–17 years
diagnosed with ADHD and found that 24 of them had elevated scores
for symptoms of ASD. The prevalence of ADHD symptoms in children
diagnosed with ASD has been reported to be between 13% and 50%.
There is substantial evidence of various similarities between ADHD
and ASD. Using latent class analysis with a sample of 644 children and
adolescents, van der Meer et al. (2012) found five classes, including one
with ADHD without ASD symptoms and several with both ADHD and
ASD symptoms but no class with ASD without ADHD symptoms. Mar
tin et al. (2014) found significant genetic overlap between 727 children
with ADHD and 996 children with ASD; a significant number of genetic
variants in each group also appear in the other. Di Martino et al. (2013)
used fMRI to identify overlapping functional networks in both cortical
and subcortical areas of the brain in 151 children: 56 diagnosed with
ASD, 45 diagnosed with ADHD, and 50 typical children; their study
also identified distinctive areas of the brain that differentiated ASD
from ADHD.
It is important to note that although genetic influences are related to
problems with social interaction, language difficulties, and social anxi
ety in individuals with ASD, familial studies also identify strengths of
persons with ASD. Simon Baron-Cohen (2000; Baron-Cohen et al. 1998)
found that parents of children with ASD or Asperger’s disorder were
more likely to be engineers, physicists, or mathematicians. Ozonoff et al.
(2002) observed that genetics associated with ASD brings a certain dis
tinctive style of thinking, relating, and reacting to the world that has
both limitations and strengths.
Individuals with ADHD tend to be more fully engaged in and more
motivated for interactions with other persons than most individuals
with ASD or Asperger’s disorder, yet both share limitations that impact
their social interactions in varying degrees and various contexts. Nij
meijer et al. (2008) pointed out the following:
[A]lthough children with ADHD generally do not lack interest in other

people, they often fail to properly attune their behavior to other persons
and to constantly changing social environments. The key characteristic
of a substantial number of children with ADHD can be described as an
apparent lack of a full comprehension of the consequences of their be
havior to others. (p. 695)
These difficulties often persist in adults with ADHD just as they of
ten persist in adults with ASD, but in both groups the difficulties in so
cial interactions depend considerably on the specifics of the social
situation.
How Are Executive Functions Related

to Asperger’s Disorder and Other
Autism Spectrum Disorders?
In DSM-5, the classification of several diagnoses related to autism that
were differentiated in earlier versions of the manual was changed. Most
strikingly, the separate diagnosis of Asperger’s disorder and several
other diagnoses were removed and reclassified as aspects of the autism
spectrum. The removal of Asperger’s disorder as a separate diagnosis
was controversial and remains so, pending further research. Many re
searchers and clinicians consider having a separate diagnosis for As
perger’s disorder to be more useful because of significant differences
between it and other disorders classified on the autism spectrum (Volk
mar et al. 2014). These differences are described briefly in Chapter 12,
“Treatment Adaptations for ADHD With Various Complications.”
According to DSM-5, ASD is characterized by two major impair
ments: 1) “persistent deficits in social communication and social inter
action across multiple contexts” and 2) “restricted, repetitive patterns of
behavior, interests, or activities” (American Psychiatric Association
2013, p. 50). These may occur with or without accompanying intellec
tual impairment and with or without accompanying language impair
ment; ASD is diagnosed in one of three classes depending on the level of
support needed by the individual.
Executive functions play a central role in social-emotional function
ing, just as they do in many other aspects of daily life. Social and emo
tional functioning depend on executive functions described in the
model of ADHD presented in Chapter 2. These functions include the
following:
• Capacity to focus on the immediate situation without becoming

excessively distracted
• Capacity to shift focus as needed for changing dynamics of the situ
ation
• Ability to hold in mind what is being said and done in an ongoing sit
uation
• Capacity to inhibit excessively impulsive responses and behave
appropriately
• Ability to modulate expression of emotion
• Capacity to monitor verbal and nonverbal cues revealing others’
reactions
Summary
There is strong evidence that children, adolescents, and adults with
ADHD tend to have other learning or psychiatric disorders at some point
in their lives more often than do those without ADHD. In this chapter, I
describe research on the frequency of specific learning disorders, anxiety
disorders, depressive disorders, bipolar disorders, oppositional defiant
and conduct disorders, obsessive-compulsive and related disorders, sub
stance use disorders, and autism spectrum disorder.
ADHD is a foundational disorder that crosscuts many other psychi

atric disorders. It is more like impairment of a computer’s operating
system than impairment of a computer software program. This chap
ter’s discussion of each of these various types of co-occurrences also ad
dresses the question of why that particular type of disorder appears so
much more frequently among those with ADHD than among others in
the general population. It explains what specific executive function im
pairments underlie and impact each specific disorder.
8
Assessing Children,
Teenagers, and
Adults for ADHD
D ECADES AGO WHEN THE DISORDER NOW

known as attention-deficit/hyperactivity disorder (ADHD) was
thought of as essentially a behavior problem of young children, assess
ment was a simple task. The clinician observed and collected informa
tion about how hyperactive and impulsive the child was in school and
at home. If the child’s activity patterns were substantially worse than
what was expected for his or her age and no other cause was apparent,
the diagnosis seemed clear.
Now that this disorder is recognized as a problem in the development
and functioning of the brain’s management system, found not only in
young children but also in adolescents and adults, the task of assessment
is more complex. The clinician needs to understand the multiple, often
subtle, ways in which ADHD can impact a person’s cognitive, emotional,
and behavioral functioning in school, family life, employment, and social
interactions at various ages.
Some clinicians believe that executive functions impaired with
ADHD can be measured with a battery of neuropsychological tests,
such as the Wisconsin Card Sorting Test and the Rey-Osterrieth Com
plex Figure test, which are referred to as “tests of executive function.”
Despite the name of this group of tests, they are not adequate measures
129
of executive functions impaired by ADHD. When such a test battery is

used to assess persons with ADHD, only about 30% of those with
ADHD are found to have impaired executive functions. Barkley (1997,
2006, 2011) and Brown (2000, 2006, 2013) have both argued that all of
those with ADHD experience executive function impairments and that
this impairment can be effectively demonstrated in data from clinical in
terviews and normed rating scales but not by neuropsychological tests
of executive function.
No Single Test for ADHD

There is no single test that provides an adequate assessment for the
presence or absence of ADHD. No electroencephalogram, neuropsy
chological test, or computerized measures can capture the variety and
complexity of functions involved in getting up in the morning and pre
paring to leave for school or work, riding a bike or driving a car in traf
fic, reading and comprehending papers or books, participating in social
conversations, and prioritizing a variety of tasks and getting started on
what is most important while avoiding distractions yet shifting focus
when needed. Assessment for ADHD requires collection of information
about how the person functions in a wide variety of complex daily tasks
at many different times of day in many different settings.
Although, at present, no diagnostic imaging tests are adequate for
confirming or rejecting a diagnosis of ADHD, imaging studies such as
positron emission tomography and functional magnetic resonance im
aging provide helpful research data showing brain characteristics in
groups of persons already diagnosed with ADHD, but these momentary
snapshots of brain structures and function cannot determine whether
any given person has or does not have the disorder. ADHD is not like a
fracture or a tumor where imaging techniques can locate and identify
pathological changes or damage in tissues. ADHD is a functional prob
lem that involves impairments in rapid-fire communications that occur
in milliseconds within and between brain regions and between vast net
works of infinitesimal neurons.
Similarly, although ADHD involves problems with neurotransmit
ter chemicals produced in the brain, there is no blood test that can ade
quately assess those difficulties because the problems do not occur in
persisting levels of those chemicals in the bloodstream or cerebral spinal
fluid. The difficulties occur at countless junctions between infinitesimal
individual neurons where the transmitter chemicals are released and re
loaded within milliseconds.
Assessing Children, Teenagers, and Adults for ADHD 131
Clinical Assessment for ADHD

At present, the most effective way to determine whether a person may
have ADHD is a well-conducted clinical interview with the patient
(and, if possible, one or two people who know the patient well) by a cli
nician who is familiar with ADHD and with other medical or psycho
logical disorders that might produce similar symptoms in a person of
comparable age. For the clinician to adequately determine whether an
individual has ADHD and/or another disorder, the following objec
tives should be addressed:
• To learn what problems have brought the patient to seek consultation

at this particular time, how long the problems have existed, and how
much they are interfering with the patient’s daily life
• To obtain information about the patient’s cognitive abilities, adaptive
strengths, and activities as well as aspirations, stressors, and motiva
tions for personal change
• To understand the emotional and social contexts (e.g., school, work,
family life, friendships) in which these problems occur and do not oc
cur in the present and in earlier years
• To gather information about blood relatives in the patient’s immedi
ate and extended family who may be experiencing or who may have
experienced problems with attention, learning, mood, anxiety, get
ting along with people, and/or substance use, which may be useful
for considering possible genetic factors that may be contributory
• To identify current or past difficulties with development, physical
health, or medical treatments that may be affecting the patient’s cur
rent difficulties or response to treatment
• To ascertain whether the patient, currently or in the past, has had in
volvement with problematic excessive use or abuse of alcohol, mari
juana, or other drugs that may impact current functioning
• To learn about the patient’s patterns of sleep: falling sleep, staying
asleep, and awakening, as well as maintaining adequate alertness
during the day
• To get a description of the patient’s current patterns of growth, appe
tite, eating and nutrition, and/or difficulties in managing these
• To identify any current or previous assessments or treatments, psy
chological and/or medical, that the patient has utilized and how the
treatments have worked for him or her
• To gather information about any additional learning or psychiatric prob
lem that may be causing or complicating the patient’s ADHD symptoms
• To inquire about the patient’s current temperament and moods (e.g.,

depression, anxiety, pleasure)
• To educate the patient about current scientific understandings of
ADHD—its symptoms, its causes, the variety of presentations, and
possible treatment interventions
I have found that I need at least 2 consecutive hours to conduct such

an evaluation so there is ample opportunity to build rapport and gather
information without interruption.
Usually, it is helpful to conduct most of the initial interview jointly
with the patient and one or both parents or a partner or friend who ac
companies the patient as a collateral. This allows multiple inputs for more
adequate information gathering; it also provides the patient with another
person who can hear and contribute to the discussion, as well as helping
the patient to recall later what was discussed. However, it is also impor
tant for the clinician to spend some time alone with the patient so he or
she can bring up questions, facts, or concerns that may be uncomfortable
for the patient to discuss in the joint setting. If an adult is unwilling or un
able to bring a collateral to the interview, I will see him or her alone.
Some clinicians ask the patient and/or collaterals to come to the ini
tial interview having filled out rating scales used for assessment of
ADHD. I prefer to administer rating scales orally during the interview
so that I have the opportunity to see how the patient and collaterals have
understood the questions being asked, to pose follow-up questions, and
to observe where they may have different opinions about how to an
swer. This also allows me to clarify if the individual does not seem to un
derstand the question or is unclear about how best to respond.
Elements of the Clinical Interview

The following list of 13 topics and relevant questions is intended for situa
tions where the patient is old enough to participate in answering questions
and providing information. Suggestions for modifying the format when
the patient is a younger child are given in the section “Modifications of As
sessment for Younger Children.” For most of these questions, it is prefera
ble to have the patient respond first, asking collaterals (i.e., parent, spouse,
partner, or friend) to offer their responses after the patient has answered.
1. Identification of the problem. Establish the following: How did
the patient and/or parents decide to come for evaluation at this
time? What are they hoping to accomplish in this session? Are there
differences in what the patient and collaterals are hoping for from
the session?
2. Current school or work situation. Inquire: What is a typical week

day/weekend day?
If patient is a student: Ascertain school and grade level. Inquire
about what specific classes or courses are being taken, current
grades in each, what class the student likes most, and which is dis
liked or is more of a struggle. Is liking or dislike due mainly to the
subject, to the teacher, or both? Is this better or worse than the pre
vious year? If grades are low, is this due more to low test grades or to
failures in getting assignments completed on time? How are rela
tionships with teachers and other students? How much time outside
of class is spent on homework most days? How much of that time is
productive work time? How much of it is “circling the airport”?
Does anyone in the family or any tutor assist with homework?
Is there any part-time job outside of school? What do you think
you would like to do for a career after you finish school?
If patient is out of school: Ask about current employment—
responsibilities, duration of employment in current position, feed
back from supervisors, and relationships with supervisors and
coworkers. What is liked and/or disliked about the current job?
What jobs have previously been held? How did those end? If cur
rently unemployed, how long out of work? Currently looking for
work? What type of position is being sought? Expectations?
What schooling has been completed? Where and when? What
subjects were especially easy or especially difficult in previous
schooling? Grade point average? Scores on any standardized tests
taken (e.g., SAT, ACT, GRE, GMAT, LSAT, MCAT)?
3. Activities for fun. Inquire about sports, hobbies, clubs, lessons,
games, and family activities. Does the patient interact (outside of
school or job) with one or two friends regularly or a large group of
friends? Or does he or she spend a lot of free time by himself or
herself? What activities are most enjoyed? Any special skills or tal
ents in past or present?
4. Self-image. Assure the patient that you are not actually going to do
this but ask hypothetically, “If I were talking with some friends who
know you well and I asked them to describe you, what do you think
they would say?” If the patient does not offer responses quickly,
prompt with queries such as the following: Would they say you are
quite friendly and outgoing or more quiet and shy? Good sense of
humor or fairly serious most of the time? Someone who usually
keeps the rules or someone who pushes the envelope or gets in trou
ble a lot? Someone with a long fuse (it takes a lot to get you angry) or
a short fuse (you get mad quickly and often)? More of a leader, more
of a follower, or more off on your own? Someone who is super

smart, sort of smart, or not so smart compared with others your age?
5. Current living arrangements. Verify the following: Where do you
live and who lives with you? Get names and ages of each person in
the immediate family or living unit and what they currently do
(e.g., grade in school, job). Then ask the patient to say three words
to describe each one, for example, things they like to do, what kind
of personality they have, or how they are with you. Is there anyone
else who is very important to you and whom you see a lot, even if
they don’t live with you?
6. Family of origin. If the patient is not living with his or her family
of origin, ask, Who was in your family when you were growing
up? Names and ages of parents and siblings? Where is each one
now? Please say three words to describe each one. What schooling
did each have, and what kind of work do they or did they do?
7. Family stress. Explore any family strains or tensions. Are there
any special stresses that have affected you or your family over the
past few years? Moving to a different house, job-related problems,
marital problems, economic pressures? Is anybody seriously sick?
Has anyone died recently?
8. Family psychiatric history. Explain that you are interested in and
have some questions about not only immediate family but also ex
tended family: grandparents, uncles, aunts, cousins—anybody,
living or dead, who is related through blood.
• Anybody with a lot of difficulty paying attention or learning cer
tain things, perhaps good in reading but not in math or vice versa?
Anybody who seems/seemed fairly smart but did a lot better
once he or she got out of school than when he or she was in school?
• Anybody with a lot of difficulties with his or her moods, getting
seriously depressed or very hyper or very irritable?
• Anybody considered a big-time worrier or perfectionist or sub
ject to panic attacks?
• Anybody with a lot of trouble understanding or getting along
with other people?
• Anybody with serious problems with drugs or alcohol?
For any with such problems, try to find out which side of the
family, whether the problem was actually diagnosed or was just
suspected. Ask how those family members turned out or are
now. The purpose of these inquiries is to get some indication of
what problems might be in the patient’s genetic background.
9. Health. Confirm the patient’s health status. How is your health gen
erally? Do you get sick much? Any bad allergies? Any problems with
your vision or hearing? Do you wear glasses or contact lenses? Do

you take any medications regularly for anything? If so, what medi
cines and for what problems and for how long? Have you taken
other medicines regularly in the past that you don’t take any longer?
If so, what, when, and any problems with those medicines? Have
you ever been in the hospital overnight? If so, for what, when, and
for how long? How is your blood pressure? Have you ever had a
concussion or other head injury? Loss of consciousness? If so, when
and what happened? Have you ever had a seizure? Has your doctor
told you that you have thyroid or any other medical problems?
Were there any problems during the pregnancy, your delivery,
or your early infancy? Any problems with colic, difficulty being
comforted, or chronic ear infections? What was your level of activ
ity as a toddler—high, average, or low? Any delays or problems in
learning to crawl, walk, or talk? Any problems with clumsiness or
coordination? Any difficulties with speech, language, or basic
math or reading skills?
10. Substance use/abuse. (Note: Do not ask adolescents or young adults
these questions while their parents are in the room. Instead, ask the
parents whether they have any reason to suspect that their son or
daughter has a problem with smoking cigarettes, drinking alcohol,
or using marijuana or any other drugs. In a private session with the
adolescent or young adult, reassure him or her that you will not
share with anyone else what he or she tells you, then ask the follow
ing questions directly as you would an adult. If the patient uses gen
eral terms like “not very much” or “only once in a while,” ask him or
her to be more specific, for example, “How many times a day or in a
typical week?” Also, ask how the use of any of these substances af
fects him or her and whether he or she has had periods when his or
her use was more excessive or problematic.)
• How much beer, wine, or liquor do you drink? How often? Ear
lier use?
• How much do you smoke cigarettes? How often? Earlier use?
• How much marijuana do you smoke/vape/dab/eat? How of
ten? Earlier use?
• Do you use any street drugs (e.g., coke, heroin, ecstasy, oxy-
Contin)? Which ones? How many days per week? How much
do you use at a time? Earlier use? (Try to get specific.) Do you
use any drugs not prescribed for you?
11. Sleep and alertness. Explore the patient’s sleep patterns. What time
do you usually get into bed on nights when you have school or work
the next day? If you get into bed at that time and say to yourself, “OK,
now I want to go to sleep,” how long does it usually take for you to
actually fall asleep? How many nights in a typical week does it take
you more than half an hour to get to sleep? Once you fall asleep, do
you sleep through the night, or do you get up to use the bathroom or
get a drink? If you wake up during the night, how long does it usu
ally take you to get back to sleep? How difficult is it for you to get up
and out of bed in the morning when you must go to school or work?
Can you get up by yourself with just an alarm clock, or do you need
another person to wake you up? Do you snore when you sleep? If
you do snore, do you sometimes hold your breath while you’re
sleeping, so someone nearby might think you’ve stopped breathing?
How often are you late to work or school when it is your fault? If you
are late, how late are you? During the daytime, do you find that you
get drowsy and have a hard time keeping yourself awake? Do you
take naps? If so, how often and usually for how long?
12. Appetite and physical development. Ask about the patient’s
physical development and concerns. How is your appetite? Are
you a big eater or not such a big eater? How much do you weigh?
Has your weight been stable over the past year or has it gone up or
down a lot? Are you satisfied with your current weight or do you
think a lot about how you would like to weigh less or more? How
tall are you? (For a child or adolescent, pose the following ques
tions: How big are you compared with most other kids your age?
When was your fastest growing time over the past few years? For
a female of appropriate age, inquire about the following: Are your
menstrual periods regular? Any significant changes in your per
iods over the past year? Do you tend to have a lot of moodiness or
discomfort during or a few days before your period?)
13. Current moods. Explore the patient’s state of mind. What has been
your mood most of the time in recent months? Do you think you
feel sad or unhappy any more than most others your age? Do you
think you worry any more than most others your age? Do you
think you have any more trouble getting along with others than
most others your age? Do you think you get frustrated or irritable
or lose your temper any more than most others your age?
Screening for Possible Co-occurring

Disorders
Throughout the clinical interview, the clinician should be alert to any
comments from the patient or collaterals that suggest symptoms of a dis
order in addition to ADHD. If there is an indication that the patient has
significant difficulties that might suggest another disorder, make some

inquiries to obtain a clearer picture of how and when those problems are
noticed, for example, “You mentioned that you tend to be very moody.
Could you tell me a bit about how your moods shift and what seems to
cause the shifts?” or “You mentioned that you often tend to check repeat
edly to be sure you have everything before you leave the house. Are there
any other routines you need to follow—counting things, arranging
things, repeating things—that don’t make a lot of sense even to you, but
you feel you have to do them or you don’t feel right?”
It is not only possible for children and adults with ADHD to have an
other learning or psychiatric disorder in addition to ADHD, it is much
more likely than for most others who do not have ADHD. Learning dis
orders and the most common psychiatric disorders found among chil
dren and adolescents with ADHD are shown in Table 7–1 (Chapter 7,
“How and Why Other Disorders Often Co-occur With ADHD”). The
percentages of more than 61,000 children and adolescents 6–17 years old
with or without ADHD who were found in this large research study to
also have a specific disorder are indicated.
Often the child or adolescent with ADHD has more than one addi
tional disorder. One-third of the children in that study who had ADHD
had at least one comorbid disorder, 16% had two, and 18% had three or
more additional disorders (Larson et al. 2011).
According to the National Comorbidity Survey Replication study,
adults with ADHD are more than 6 times more likely than those with
out ADHD to have at least one additional psychiatric disorder at some
point in their lifetime. They are 5 times more likely to have depression
or some other mood disorder, 3.7 times more likely to have one or more
anxiety disorders, 3 times more likely to have a substance use disorder,
and 3.7 times more likely to have disruptive, impulse-control, or con
duct disorders, such as oppositional defiant disorder or intermittent ex
plosive disorder; bulimia; or gambling problems (Kessler et al. 2006).
It should be noted, however, that Larson et al. (2011) and Kessler et al.
(2006) are not reporting that the children or adults with ADHD had these
problems continuously throughout their lifetime. Instead, these high num
bers reflect how many individuals had one or more of these additional dis
orders at some time in the lifetime. If there is an indication that patients
being assessed have had symptoms of one or more additional disorders, it
is important for the clinician to ascertain whether the problems were very
recent and still affect the patient, whether the problems are in the past and
have no current effect, or whether problems are ongoing or possibly recur
rent. Information about how treatment for ADHD may need to be modified
for patients also experiencing a concurrent disorder or with a history of a
significant disorder is included in Chapter 12 (“Treatment Adaptations for

ADHD With Various Complications”).
Administration of ADHD
Rating Scales
After obtaining a careful history, I administer a normed rating scale for
ADHD appropriate for the age of the patient. Among the possible
choices are the Barkley Rating Scales (Barkley 2011, 2012a), the Brown
ADD Rating Scales (Brown 1996, 2001), the Brown Executive Function/
Attention Rating Scales (Brown, in press), and the Conners ADHD Rat
ing Scales (Conners 2008a; Conners et al. 1999), all of which are available
in versions normed for age groups across the life span. First, I hand out
3-inch×8-inch cards on which are written the patient’s possible response
numbers; each card has one to three words defining what the number
means. For the Brown scales, the objective of the card system is to deter
mine not only how often a problem occurs but also how much trouble
that problem makes for the person (Table 8–1). The clinician is seeking
information about both the frequency and the intensity of the problem.
I then explain to the patient and collateral that I will be reading a list of
problems that people sometimes have; after each problem is read, I will
ask the patient to say the number that best indicates how applicable the
problem is for him or her (not over his or her whole life but just over the
past 6 months). I suggest rounding up if the patient is stuck between two
numbers. I request that if the patient is unsure about what I am asking, he
or she tells me; in that case, I try to rephrase the item to make it more un
derstandable. I prefer to ask the patient to respond first and then to have
the collateral reply to the same item, immediately after the patient has re
sponded. I ask the collateral to select responses based on integrating what
he or she has seen with his or her own eyes or heard in talking with the pa
tient or in the opinions of others (e.g., family members, teachers), assum
ing those opinions are considered reasonable. I emphasize that the
respondents do not need to agree in their responses to each item. The cli
nician is interested in how each individual sees the situation from his or
her own point of view. It is also important to keep participants from trying
to persuade one another that they should change an answer already given.
DSM-5 Diagnostic Criteria

After completing the rating scale, I explain that there is one additional set
of problems to ask about and that now just a “yes” or a “no” response is
TABLE 8–1. Response options for Brown Executive Function/

Attention Rating Scales
Severity Frequency
0=No problem Never

1=Little problem Once a week or less
2=Medium problem 2–3 times a week
3=Kind of a big problem Almost every day
needed. “Yes” means that the patient has much more difficulty with that
problem than most others of the same age; “no” means that the patient
may have the problem but not in a way that is worse than in most anyone
else of the same age. After verifying that all respondents understand the
directions, I read aloud each of the nine ADHD symptoms of inattention
and each of the nine ADHD symptoms of hyperactivity/impulsivity. I
elicit and record a response from the patient and collateral, noting any
item for which, on the basis of all available data, I would assign a differ
ent response.
Brief Measures of Working Memory

When taking a patient’s history and administering a normed ADHD
rating scale along with considering the DSM-5 criteria (American Psy
chiatric Association 2013), the clinician is working primarily with just
self-report data provided by the patient and observer-report data pro
vided by parents, partner, or other collateral participant. These reports
can be a very rich source of information about the patient’s past and
present functioning in a variety of contexts, particularly when the clini
cian is skilled in eliciting relevant facts and examples while curtailing
digressions that are unlikely to contribute to the diagnostic process.
However, it is also useful to administer a couple of brief objective mea
sures to directly assess the patient’s working memory, for both verbal
and numerical information.
Working memory is one of the primary impairments for most per
sons with ADHD. Although there are multiple aspects of working mem
ory, some important aspects can be assessed with brief standardized
measures. For virtually every patient, regardless of age, I use a story
memory task and a digit span test. For adults and adolescents 16 years
or older, I use the two auditory verbal memory tasks provided in the
Wechsler Memory Scale, 3rd Edition (Wechsler 1997); they are identi
fied as the Logical Memory test. This measure consists of two stories,
each about one paragraph long with 25 word units, and a good scoring
system with norms for various age groups from 16 to 89 years. My pro
cedure is to say to the patient, “I’m going to read you two short stories;
each is just a paragraph. Please listen carefully. After I read the first story
to you, I’ll stop and ask you to repeat that story back to me, with as close
to the same words as possible, without making any changes. I don’t ex
pect you to remember every word of the story—there are too many
words for that—but I am asking you to pretend you are a tape recorder
and say it back to me with as close to the same words as you can.” Im
mediately after reading each story, I stop and ask the patient to repeat it
back to me, without my giving any prompting except to ask, when the
patient has said what he or she can recall, “Anything else? Even if it’s
out of order, that doesn’t matter.” As the patient responds, I check off
each word unit on the scoring sheet. The whole process is then repeated
with the second story. More details on this measure are described by
Kennedy et al. (2016). For children under 16 years, I use the Children’s
Memory Scale (Cohen 1997), which has stories and scoring systems for
three different age groups as well as items for a test of digit span for
ward and backward with age-based norms for each age group.
After the two stories have both been repeated back to me, I admin
ister a standard digit span test. I say to the patient, “Now I’m going read
you some numbers and ask you to say them back to me in the same or
der that I say them to you.” I then read the various strings of numbers,
allowing about 1 second for each number and trying to avoid any
chunking of the numbers that might give an unfair advantage. This is
continued with each pair of number strings from 2 to 9 digits each until
the patient misses two strings in one set or completes all the examples. I
then say, “Now I’m going to say some more numbers, and this time I’m
going to ask you to say the numbers back to me in reverse order. For ex
ample, if I say ‘1, 2’ you would say ‘2, 1.’ ” When we have completed
both the digits forward and digits backward, I thank the patient and
then go on to take some additional history. After about 15–20 minutes, I
stop and say, “Now I’d like to ask you to go back for a minute and tell me
again anything you can still remember from that first story I read to you
a few minutes ago.” After listening and scoring the patient’s response, I
then ask him or her to tell me what he or she can recall from the second
story I read. The response is then scored and set aside while we go on to
the next segment of the clinical interview. I do not give the scores on
these measures to the patient until the remaining sections of the evalu
ation are completed and it is time to report the diagnosis.
Explanation of ADHD With Queries

After completion of the patient history, rating scales, and brief memory
assessments, I ask the patient and family to tell me briefly what they know
about ADHD. Some patients come with an impressive amount of gener
ally accurate information that they have obtained from careful reading of
reliable books and articles about ADHD or from participation in the orga
nization Children and Adults with Attention-Deficit/Hyperactivity Dis
order (CHADD) or the Attention Deficit Disorder Association (ADDA) or
from courses they have taken. Others come with virtually no information
or with a lot of misinformation. This can be a good opportunity to clarify
misconceptions and to see if there are any significant differences between
patient and parents or between parents themselves in their understand
ing of ADHD and their motivation to obtain treatment.
Even with grade school children, it can be helpful to ask the child pa
tient what he or she knows about ADHD or if the child knows anyone
who has ADHD. Not infrequently, child patients report that they know
a kid at school who has ADHD and that he is a real troublemaker who is
not very smart and doesn’t seem to care much about following the rules
or getting his work done. In those situations, it is important for the cli
nician to point out that while some children with ADHD have behavior
problems like that, there are many others with ADHD who are very
smart, have no noticeable behavior problems, and work hard to do well
in their schoolwork. If the only examples of ADHD known to the patient
are peers with notorious behavior problems, that is likely to have a neg
ative impact on how comfortable the child will feel if it is determined
that he or she has ADHD. The patient is not likely to want to “join the
club” of the class troublemaker.
After taking a few minutes to clarify the ideas about ADHD held by
the patient and family, I usually say, “Now, I’d like to tell you how I think
about ADHD because recent research has brought about many changes
in how we understand this disorder. As I do that, I will stop from time to
time to ask you (the patient) and your parents (or other collaterals) to tell
me how much that part of ADHD that I have just described fits or does
not fit you.”
After that introduction, I give a brief description of the six clusters of
the model of ADHD-related executive functions described in Chapter 2
(“A New Model of ADHD”). I describe each cluster briefly using several
examples. I then ask the patient and collaterals to say how much that clus
ter of symptoms fits or does not fit the patient’s usual patterns of behavior.
There are two purposes for this description. First, it is an attempt to
provide the patient and collaterals with an updated, science-based
grasp of ADHD in clearly understandable language adjusted to their

age and educational level. It can help to correct misinformation and to
inform them of the nature and scope of impairments involved in this
disorder. Second, by asking a couple of direct questions about how the
description of those symptoms fits or doesn’t fit the patient’s experi
ence, I can gain additional information to help me develop a more ade
quate base of information for making a diagnosis. Usually, I spend
about 20 minutes on this portion of the clinical interview.
Following this description of the model of ADHD-related impair
ments of executive function, I ask the patient and collateral what they
know about how people get ADHD. Many, but not all, are aware that
this is a highly heritable disorder. I take just a few minutes to explain
that out of every four persons diagnosed with ADHD, one has a mother
or father who has had the disorder, whether the parent was aware of it
or not. I also explain that among those who do not have a parent with
ADHD, many have a grandparent or sibling or uncle or aunt who has or
had the disorder. I mention that in past decades, and often in the pres
ent, children and adults with ADHD are not recognized as having this
disorder because many clinicians have not received adequate training to
correctly diagnose it.
At that point, I take a few minutes to explain our current under
standing of what happens in the brain that causes symptoms of ADHD.
I show a life-size plastic model of the human brain and explain that it is
made up of 100 billion neurons. To help the patient and collaterals to
imagine this, I point to my computer monitor and say that there are ap
proximately 200,000 pixels on that screen. I ask them to imagine a sky
scraper 110 stories high that has been totally covered with TV screens
the size of my computer monitor. Once they capture that image, I tell
them that if all the screens covering that huge building on all sides and
all 110 floors were turned on and we could count all the pixels on all
those screens, we would then have enough pixels to correspond to how
many neurons one person has in his or her brain.
I then pick up a pad and make a simple drawing of a neuron with its
branch-and-twigs organization and explain that these massive numbers
of neurons communicate with one another using low-voltage electrical
impulses. I then make a simple drawing of a synapse and explain the
amazing fact that at their countless connection points, neurons do not
actually touch one another; there is a gap between neurons for every
one, not just for those with ADHD but for all of us.
Using the drawing, I then show that each message traveling along the
neuron must jump the gap between neurons, much as the energy of a spark
plug jumps its gap. This paves the way for showing that this jump across
the synaptic cleft is facilitated by chemicals produced in the neurons and

sitting in little bubbles near the edge of the gap. I mention that the electrical
charge then attaches to receptors sitting on the receiving end of the oppos
ing synapse and that if the electrical charge comes across strong enough, it
quickly jumps the message along to subsequent neurons in the network to
get it to where it needs to go. If the charge is not strong enough, it can fizzle
at that neuron. In either case, release of the mini dots of the transmitter
chemical is quickly followed by action from proteins on the sending side
that operate like little vacuum cleaners that suck back the remaining trans
mitter chemical and repackage it for further action. I note that this action of
release and reloading happens very quickly, so that 12 or more messages
can cross that gap within one-thousandth of 1 second.
This description may appear very complicated, but when illustrated
with drawings and adapted for the educational level of the patient and/or
collaterals, it can usually be understood, at least in basic terms. Once that
is said, I can explain that one important aspect of the problem in the brain
of persons with ADHD is that those neurotransmitter chemicals are not
efficiently released or reloaded, often causing some messages not to get
across the gap adequately, unless they relate to something in which the
person has strong personal interest or strong fear.
This leads me to say that for about 8 of 10 individuals with ADHD,
carefully prescribed medication can improve this process. I emphasize
that medication for ADHD cures nothing; it is not like an antibiotic that
may cure an infection. This medication is more like eyeglasses that help
someone improve his or her vision but only while individual is wearing
those glasses. For some, medication brings huge improvement; for oth
ers, it is substantial, but not huge; for still others, medication helps a lit
tle, but not that much; and for about 2 of 10, medications currently
available for ADHD do not improve functioning much at all.
Some will question whether it is necessary to take time to try to ex
plain to patients and collaterals information about the nature of the
problems in the brain for individuals with ADHD and about how the
medications work. However, I have found that, except for very young
children, most patients and parents or other collaterals appreciate re
ceiving at least basic information about the brain processes involved in
ADHD-related impairments and the basic elements of how medications
for ADHD work. Such understanding often increases willingness of pa
tients and their families to collaborate in the sometimes frustrating pro
cess of developing an effective treatment program.
After offering this elementary information about the biology of
ADHD and mechanisms of action of medications for its treatment, I re
focus the discussion to address the question of whether the patient does
or does not have ADHD. I say that there is no one test that can say for
certain whether a person has ADHD or not. I explain that we look at all
the information we have regarding the person’s current functioning and
earlier history to see what is easy for him or her and what is difficult; we
see how the patient does on remembering the stories and the numbers;
we look at what he or she and the collaterals say on the rating scales; we
consider whether there are any other problems that are complicating
things; and then we try to put the pieces together.
I then briefly summarize what I have learned about the patient’s
strengths and current difficulties, also mentioning relevant stresses and
supports. In that context, I offer my impression that the patient does or
does not meet diagnostic criteria for ADHD and/or any related disorders.
I cite the data that support my diagnostic impression. I show the summary
scores on the listing of DSM-5 diagnostic criteria, the obtained scores on
the story memory task and the digit span test, and the summary scores on
the ADHD rating scale that he or she and the collaterals helped to com
plete. If other disorders are occurring concurrently, I also mention those
disorders. Often in this discussion, I utilize the circles inside squares
graphic organizer described in Brown (2005b), which is available on my
Web site (www.DrThomasEBrown.com). At that point, I usually inquire as
to whether what I have just said makes sense to the patient and collaterals.
I also invite and respond to any comments or questions they raise.
Following that discussion, I ask the patient and collaterals to consider
what they want to do about the problems represented in this diagnosis.
One option, of course, is to do nothing at present, to simply wait a while
and see how things work out. Another option is to consider the possibility
of further testing, for example, psychoeducational testing to assess for pos
sible learning disorders or to ascertain eligibility for accommodations in
school or work under Section 504 of the Rehabilitation Act of 1973, the In
dividuals with Disabilities Education Improvement Act, or the Americans
with Disabilities Act. Another option is to undertake a trial of treatment
with medication to try to alleviate the patient’s ADHD symptoms. Possible
benefits, costs, and potential risks of each of these options can then be dis
cussed. More information about various treatment options is offered in
Chapters 10 (“Practical Aspects of Medication Treatments for ADHD”), 11
(“Practical Aspects of Nonmedication Interventions for ADHD”), and 12.
Modifications of Assessment
for Younger Children
When younger children are brought by their parents for assessment of
possible ADHD, modifications need to be made to address the specific
needs of the child. For very young children, I usually begin by reassur
ing the child that this doctor visit is not going to involve getting any
shots. Many children assume that anytime they are brought to see a doc
tor, they will very likely be getting an injection. It can be helpful to re
move this fear at the outset.
In the beginning of the interview, I usually try to engage the child in
some conversation at whatever level he or she can participate, depend
ing on the age, verbal abilities, and willingness of the child to interact
with me. I usually explain that I will need to be asking lots of questions:
“Some questions will be for you, some will be for your parents, and oth
ers will be for all of you.”
If you do not structure the interaction very soon after everyone is in
the room, it is likely that the parents will begin a lengthy description of
problems they see in their child, possibly embarrassing the child so
much that he or she will be unwilling to respond directly to any ques
tions from the clinician.
Usually, I begin with simple questions that the child is likely to be
able to answer easily, for example, What is the name of your school?
What grade are you in? What is your teacher’s name? Do you like your
teacher? Do you think he or she likes you? How are the other children in
your school—are they usually friendly or are some of them mean to
you? Of all the things you do at school, what do you like the most?
Which things are the most difficult for you? What do you like to do for
fun when you’re not in school? Do you have one or two kids you play
with a lot, or a whole big bunch of kids you play with, or do you do a lot
of stuff by yourself?
After eliciting such information, I usually ask the young child to draw a
picture for me. I have the child sit at a small table where he or she can work
in the same room with his or her parents and me. I offer either crayons or
markers with some drawing paper. I ask the child to draw a picture that has
three things in it: a house, a tree, and a person. I suggest that he or she can
put in anything else they choose, but I ask the child to remember to put in at
least those three items. I then turn my attention to the parents, asking them
what they are hoping we can accomplish together in this consultation. I
then begin raising the questions described in the paragraphs above while
also keeping an eye on the child, noticing level of engagement in the task
and skill in doing the drawing. When the child is finished with the picture,
depending on the child’s age, I may ask the child to print his or her name
and to write the alphabet and a series of numbers or simple math problems
suitable for the child’s age. Once these tasks are completed, I usually offer
the child a limited number of choices for play: a box of Legos, some models
of animals and action figures, or paper for drawings of anything he or she
chooses. Some children prefer to play with toys they brought with them.
Usually, I allow the child to stay in the room while the parents and I are talk
ing so the child can hear what is happening and, if he or she wishes, join in
the conversation, so long as the child does not disrupt it. Meanwhile, I also
am observing how the parents are or are not interacting with their child.
Additional Resources Useful

for the Evaluation of ADHD
and Related Problems
Books
A useful book providing comprehensive information for evaluation of
ADHD in children and adolescents is Essentials of ADHD Assessment for
Children and Adolescents by Sparrow and Erhardt (2014). A helpful guide
for assisting parents concerned about the diagnosis of their child with
ADHD or related disorders is Quirky Kids: Understanding and Helping
Your Child Who Doesn’t Fit In—When to Worry and When Not to Worry by
Klass and Costello (2003). For assessment of ADHD in adults, the book
Could It Be Adult ADHD? A Clinician’s Guide to Recognition, Assessment,
and Treatment by Jan Willer (2017) can be helpful.
Report Cards or School or College Transcripts

Report cards or transcripts of high school or postsecondary schooling
may provide some useful information about the patient’s past or cur
rent strengths and difficulties in academic work.
Teacher Evaluations
For children who are in prekindergarten through elementary school, it is
often quite helpful to obtain information from the teachers who spend the
most time with them. Often teachers will provide useful information in
notes or on teacher forms for rating ADHD symptoms. This is most true
when the child is in one class with the same teacher most of the day. For
older students (e.g., in middle school or high school) who are changing
classes throughout the day, most teacher reports may not be as helpful be
cause the teachers do not have as much sustained opportunity to get to
know individual children in so many aspects of their school activities.
Psychoeducational Testing Reports

Cognitive testing such as IQ tests and individualized achievement test
ing may provide additional information about the patient’s strengths
and difficulties, but such measures are not necessary for making a diag
nosis of ADHD. Some individuals seeking evaluation may already have
had such testing recently or much earlier. If one or more reports of such
evaluations are available, it may enhance the clinician’s understanding
of the patient’s cognitive abilities. Commonly used measures for such
assessment include the Wechsler Intelligence Scale for Children—Fifth
Edition (WISC-V; Wechsler 2014), the Wechsler Adult Intelligence
Scale—Fourth Edition (WAIS-IV; Wechsler 2008) IQ tests, and the
Woodcock-Johnson IV Tests of Cognitive Abilities (Woodcock-Johnson
2016a). Achievement tests include the Wechsler Individual Achieve
ment Test-III (Wechsler 2009) and the Woodcock-Johnson Achievement
Tests-IV. Often students diagnosed with ADHD and seeking educa
tional accommodations such as extended time for taking exams are re
quired to submit results of such measures of ability and achievement.
Another measure often helpful for assessing need for extra-time accom
modations is the Nelson-Denny Reading Test (Brown et al. 1993). This
measure for adolescents and adults allows assessment of the individ
ual’s vocabulary and reading comprehension abilities under both stan
dard and extended-time conditions.
For students who have significant difficulties in learning a foreign
language and who are seeking a waiver from foreign language require
ments, the Modern Language Aptitude Test may be a useful assessment
measure (Carroll and Sapon 2002).
Broader Screeners for Behavioral and

Emotional Functioning
The following four instruments are often used to assess for a wide range
of behavioral and emotional functioning difficulties:
• Behavioral Assessment for Children—Third Edition (BASC-3; 2–21

years) (Reynolds and Kamphaus 2015)
• The Child Behavioral Checklist (CBCL; 4–18 years) (Achenbach 1991)
• Conners’ Comprehensive Behavior Rating Scales (6–18 years) (Con
ners 2008a, 2008b)
• Vineland Adaptive Behavior Scales—Third Edition (birth to 90 years)
(Sparrow et al. 2016)
Scale for Autism Spectrum Screening

The Social Responsiveness Scale—Second Edition is a well-researched
instrument to screen for problems related to the autism spectrum in chil
dren and adults. There is a preschool version for ages 2.5–4.5 years, a
school-age form for ages 4–18 years, and both observer and self-report
forms for adults age 19 years and up (Constantino and Gruber 2012).
Instruments Less Helpful

for Assessment of ADHD
A number of computerized tests are being marketed for “objective” as
sessment of ADHD. The most common is the Continuous Performance
Test (CPT). Typically, these computer programs, such as the Conners’
CPT-II, the Integrated Visual and Auditory 2 (IVA-2), and the Test of
Variables of Attention (TOVA 8.0), run about 15–22 minutes to rapidly
present the individual with a series of letters or shapes on the computer
screen and/or with auditory signals. The person is asked to respond
when a particular target appears while avoiding responding to other
stimuli. A printout then compares the individual’s performance with a
series of scores comparing response speed and patterns of responding
or not responding with sample norms. Some, like the Quotient and
QbTest, also utilize a motion monitor to assess for hyperactive head
movements while the individual is taking the CPT.
These computerized tests are inadequate measures of the complex
range of functions now understood to constitute ADHD. Moreover,
they consume a significant portion of the limited time available for a di
agnostic assessment. Also, contrary to claims by some who sell such de
vices, performance on a CPT cannot be used as a valid measure to assess
the effectiveness of medication treatments for ADHD; that task requires
longer-term self-report data regarding functioning of the patient in
many different types of tasks and activities at various times of day.
Another set of measures not very helpful in assessing for ADHD is a
battery of neuropsychological tests. There is a collection of neuropsy
chological tests often referred to as “tests of executive function.” These
include various laboratory measures such as the Stroop Test (Stroop
1935), Wisconsin Card Sort (Heaton et al. 1981), Tower of Hanoi/Tower
of London (Shallice 1982), and Rey-Osterreith Complex Figure (Waber
and Holmes 1985), all of which are administered by a neuropsycholo
gist, usually in a small office setting. These tests have proven helpful for
identifying certain neurological impairments such as brain damage
from stroke or trauma, but they are not effective for assessing impair
ments of executive functions identified in the model of ADHD pre
sented in this book.
If executive function impairment is defined as getting very low
scores on neuropsychological “tests of executive function,” only about
30% of children or adults diagnosed with ADHD appear to have signif

icant executive function impairments. Paul Burgess (1997) argued
against trying to assess executive function impairments with such sim
ple tasks. He stated:
Goethe’s famous comment that dissecting a fly and studying its parts
will not tell you how it flies could almost have been intended for the
neuropsychology of executive function. . . .[E]xecutive functioning is
called into play only when the activities of the cognitive architecture
must be coordinated....Thus, if a methodology is used where a task is
broken down into its component parts, no deficit will be discovered in
dysexecutive patients. (pp. 99–102)
R.A. Barkley (1997, 2012b, 2015) and I (Brown 2000, 2005a, 2006, 2013)
claim that all children and adults with ADHD suffer from significant ex
ecutive function impairments relative to others of similar age and that
developmental impairments of these executive functions are the es
sence of ADHD. We assert that these impairments can be seen much
more clearly and validly in assessments of how individuals with ADHD
perform over time in a wide variety of tasks for which they need to man
age themselves than in any battery of neuropsychological tests.
Summary
Given that all persons have some of the symptoms of ADHD sometimes,
it is important to have an effective way to determine which individuals
experience sufficient chronic impairment from ADHD symptoms to
warrant diagnosis and treatment. There is no single test for ADHD—no
laboratory test, genetic test, computer test, imaging test, or battery of
neuropsychological tests that can adequately determine which individ
uals meet diagnostic criteria for ADHD and which do not.
The complexity and situational specificity of ADHD symptoms re
quires information about how the individual functions in a wide variety
of situations and tasks of daily life relative to others of the same age. The
most effective tool for diagnosis of ADHD is a well-conducted clinical
interview with the patient (and, if possible, one or two people who
know the patient well) by a clinician who is familiar with ADHD and
with other medical or psychological disorders that might produce sim
ilar symptoms in a person of comparable age.
This chapter includes a thorough outline of what a comprehensive
clinical evaluation for ADHD should include for various age groups. It
also describes some instruments advertised for use in clinical evalua
tions that are less helpful for assessment of ADHD.
9
Emotional Dynamics
in Individuals,
Couples, and Families
Coping With ADHD
THERE IS NO SINGLE PROFILE OF EMOTIONS
common to all individuals with attention-deficit/hyperactivity disor
der (ADHD). There is much diversity due to differences in age, temper
ament, personality style, family life, cultural background, and many
other variables. Yet there are some ADHD characteristics and some sit
uations often experienced by many with ADHD (and those involved
with them) that cause particular patterns of emotional dynamics to
emerge more frequently among these individuals. In this chapter, I de
scribe some emotional dynamics often reported by children, adoles
cents, or adults with ADHD and those who interact with them.
The palette of human emotions is rich and variegated. It includes
happiness, enthusiasm, interest, disinterest, boredom, delight, worry,
fearfulness, panic, terror, frustration, annoyance, anger, rage, pride,
envy, embarrassment, shame, guilt, jealousy, disappointment, discour
agement, grief, hopelessness, sadness, depression, longing, trust, opti
mism, expectancy, determination, affection, passion, love, hope, and
many other emotions.
151
Emotions are dynamic in that they often change and interact, some
times in an instant, sometimes over hours, weeks, or years. Often they
change in response to specific circumstances of a situation, what some
one else says or does and how individuals perceive and react to one an
other in given moments and over time. Sometimes emotions are quite
transient, a flash of anger or a moment of jealousy, pride, or affection
that may quickly be modified or replaced by other emotions that may be
quite contradictory. Emotions may also be persistent over much of a life
time, absorbed into the fabric of one’s personality across differing set
tings.
Emotions vary not only in type but also in intensity. Sometimes emo
tions arise with fierce or crushing intensity; at other times, that same
emotion may be scarcely noticeable. Emotions also vary in level of con
sciousness. Sometimes a person is fully aware of a particular emotion in
a given moment, yet at another time, that person may be totally un
aware of an emotion that others readily recognize and respond to.
In all persons, emotions tend to arise in multiple mixes and blends.
Sometimes the blend is subtle and convergent—affection and longing,
pride and hope. In other instances, emotions strongly conflict with one
another—interest and fear, pleasure and guilt, pride and resentment,
love and hate. Sometimes the conflict is immediate; in other instances,
one emotion may be followed quickly or gradually with another, or a
person may experience rapid alternation between one emotion and an
other. Examples of emotions described in this chapter may be experi
enced by various individuals in many different ways, only some of
which are included here.
Case Example: A 7-year-old who feels
picked on by adults
Seven-year-old Jimmy’s mother met him at the front door as he came

home from school. She gave him a hug and asked, “How was school to
day?” Jimmy dropped his schoolbag and jacket on the floor in front of
the door and, without answering, headed toward the kitchen to find a
snack. His mother called him back to pick up his jacket and schoolbag.
Jimmy came back with a grumpy face and announced, “School was ter
rible; it’s always terrible. She’s always yelling at me just like you are
now!” His mother responded, “I wasn’t yelling at you, I just asked you
to come back to pick up your jacket and schoolbag and put them where
they belong, not just leave them in front of the door.” Jimmy picked up
his stuff grumbling, “It’s always that way, you and my teacher and my
soccer coach, all of you are always yelling at me and saying that I did
something wrong or didn’t do something I was supposed to do. Nobody
else ever gets yelled at so much all the time.”
Emotional Dynamics of ADHD 153
Young children with ADHD, especially if it is not effectively treated,

often complain that their parents, teachers, and other adults are con
stantly yelling at them. This “yelling” may sometimes involve angry
comments with a raised voice. Although often it is simply a matter of
very frequent reminders and corrections that may be necessary, they
may leave the child feeling singled out, far more often than other chil
dren, as the one who is not doing what is expected. Many teachers and
parents of children with ADHD report that they need to give reminders
or corrections to these children as many as 5–10 times more often than to
most of their classmates or siblings.
Even when these frequent corrections are done with minimal inten
sity and without any overt annoyance, the impact on the child’s view of
self may be substantial. When this pattern goes on with much daily fre
quency for many years, as it does for some children with ADHD, the re
sult is often a combination of feeling picked on, unappreciated, and
incompetent, relative to others of similar age.
One antidote to this problem is for parents and teachers to find or
create frequent opportunities to recognize when their child is doing
something well so they can give recognition or praise for doing the right
thing. In the routines of daily life, it is easy to mention mostly the actions
one finds frustrating or wants to see changed. Acknowledgment of ap
propriate, nonproblematic behaviors that one would like to see more
frequently and to reinforce can often be overlooked.
When a child complains about others being too critical or getting too
irritable with him or her, it may be helpful to listen to the child’s com
plaint and perhaps offer some empathy or validation: “Yeah, it’s not
much fun to feel like you’re always the one getting told you’re in the
wrong. Sometimes it may be that you really are doing something you
should change, but other times it may be that the grown-up is just hav
ing a bad day.” Sometimes such complaints are an indirect way of ask
ing for some recognition and encouragement to counter frustrations of
the day.
Case Example: An 8-year-old with outbursts
of rage followed by guilt
The parents of 8-year-old Michael explained, “He’s very polite and well
behaved 90% of the time, but several times a day, like when we have to
tell him to do a simple thing like turn off a video game he’s playing so he
can start getting ready for bed, he often, but not always, will fly into a
rage, swear at us, and head-butt us, and then keep kicking against a
door. This goes on for about 10 or 20 minutes, and then he starts crying
and says, ‘I can’t move, I’m stuck, come help me.’ He wants one of us to
come hold him quietly for a minute or two, then he tells us he’s very
sorry for being so bad, and then it’s over, and he’s all good again until
the next time.” Michael’s mother shook her head and said, “We’ve tried
systems to reward him for any day without these meltdowns, but that
didn’t help at all.” His father said, “When he does that stuff, it makes me
so mad that I start screaming at him, even though I know that does no
good at all and probably makes it worse.” Michael’s parents also re
ported, “He’s had a few episodes at school where he had meltdowns and
hit other kids; he got suspended twice, but those are rare. Mostly, this
just happens at home.”
Two years prior to my seeing him, Michael had been diagnosed by

another doctor as having ADHD; she prescribed some stimulant medi
cation for him, but that had to be stopped because it intensified the melt
downs and anger outbursts. I arranged for Michael to begin a trial of a
nonstimulant medication to help him control his intense episodes of an
ger. I also met individually with Michael and with his parents, and I met
with the three of them together.
This was not just a problem with Michael; it was a problem for the
whole family and was fueled by multiple factors. Michael clearly had a
very short fuse when he was frustrated; yet his impulsive angry out
bursts were quickly followed by strong feelings of guilt and fear. Mi
chael’s father reported that his own father, his father’s father, and his
brother had all struggled with brief but intense outbursts of rage similar
to what Michael experienced. This suggested that genetic factors were
probably involved. Michael’s dad also reported that he himself felt
overwhelmed with anger and screamed at Michael with intensity any
time Michael acted angry. This intensified Michael’s anger and his fear
of his own temper and of his father.
Michael’s father also acknowledged that he himself had been diag
nosed with ADHD and was taking medication for it. Unfortunately, his
medication dosing was helping some but not much. I suggested that he
discuss the possibility of a change of medication or dosage with his pre
scriber.
The parents also explained that they were struggling with financial
pressures. The husband had been laid off and had been unable to find a
new job for more than a year. This was frustrating and embarrassing to
him because his wife was working long hours to support the family
while he was staying home taking care of the house and Michael. Mean
while, Michael’s mother was clinically depressed and also frustrated
that her husband often seemed not to be pulling his weight at home.
Both parents were often in conflict, unable to provide much emotional
support for one another or for Michael. Both clearly loved their son in
tensely and were committed to one another, but they were feeling in
creasingly frustrated with him, embarrassed that they could not control
his outbursts or their own, and hopeless about how to help him and one
another.
Case Example: An 11-year-old who
“goes on strike” when asked to write
Eleven-year-old Sandy was the best goalie on her travel soccer team. She
was well liked by her teammates and often praised by her coaches for
her skills and consistent effort. Yet she hated school. She got along all
right with her classmates and usually got passing grades, but she was
seen by her teachers as stubborn and temperamental. Now in sixth
grade, she was having increasingly frequent incidents of what the teach
ers called “going on strike.” When the class was asked to write para
graphs or brief essays, Sandy often wrote nothing. When the teacher
asked what was wrong, Sandy just stared ahead and did not respond.
When the class was given a timed challenge test for math problems,
Sandy often started with the others and then suddenly stopped, tore up
her paper, refused to talk, and began repetitively kicking the desk in
front of her until the teacher sent her to the principal, who told Sandy to
complete the work at home and return with a better attitude. Sandy’s
parents reported that it often took them 5 or 10 minutes to explain the
writing assignment to Sandy and help her get started, but then she was
able to complete the task, producing results that the teacher said were
fully satisfactory.
When I first met with Sandy and her parents, she was initially un
willing to answer any of my questions, but as I continued to talk with her
parents, she gradually warmed up and began to respond, first with just
facial expressions and nods or head shaking, then gradually with words.
Her mother told me that Sandy had been slow to speak as a young child,
producing no words until she was 3 years old, but at that point she began
suddenly to speak in sentences. I also learned that both Sandy and her
mother had been diagnosed with ADHD several years earlier and that
both were taking stimulant medication that they found helpful.
Over a series of conversations together, I found that Sandy readily
spoke with me about how her soccer team was doing, yet she was un
willing to discuss any incidents in school where the teacher had com
plained to her parents about her behavior. When her parents told me
how teachers were complaining about her being angry, being stubborn,
and going on strike, Sandy kept her head down and stared at the floor as
her eyes began to fill up with tears.
Gradually, it became clear that Sandy’s teachers were mistaken
when they interpreted her “on strike” behavior as anger and stubborn
ness. That behavior was covering intense feelings of shame and fear.
Sandy had very high standards for herself, especially for expository
writing and for math. She also had ADHD-related problems with work
ing memory and processing speed. Her working memory problems of
ten caused her to get confused about oral directions given for writing
assignments, so she did not understand and remember what she was
being asked to do. Her slow processing speed made it very difficult for
her to keep up with her classmates in doing tightly timed math chal
lenges. When she saw her classmates working much faster on the timed
math quizzes, she felt embarrassed and gave up. When she felt confused
about how to start her writing assignments, she froze in shame and was
unable to respond to the teacher’s offers of help. What appeared as op
positional behavior was, in fact, a diversionary maneuver that served to
distract her, her classmates, and her teacher from what Sandy saw as hu
miliating failure.
I asked Sandy’s pediatrician to add a selective serotonin reuptake in
hibitor (SSRI) to the stimulant medication Sandy was taking for her
ADHD; gradually that helped to reduce her chronic anxiety. I also tried
to help Sandy and her parents to understand the puzzling intensity of
her reactions to confusion and perceived failure. Her mother then re
ported that both her sister (Sandy’s aunt) and Sandy’s maternal grand
mother also had long-standing reputations in their family for quickly
getting angry and then pulling into their shell when they felt anxious,
especially when stress occurred in a social situation.
We had a meeting with Sandy’s team of teachers, who readily agreed
to give written directions for writing assignments and to provide extra
help for Sandy to learn how to get herself started on writing assign
ments. Her pediatrician, her parents, and I also arranged to make some
adjustments to Sandy’s ADHD medications to provide more help for
her problems with working memory and processing speed.
Case Example: A 12-year-old rejected
by her classmates
Twelve-year-old Jessica wasn’t eating much and was unusually quiet at

the dinner table as her parents, brother, and sister were enjoying the
meal and exchanging stories about events of the day. Noticing that Jes
sica didn’t seem her usual self, her father said, “Jessica, is there some
thing wrong? You don’t seem to be your regular self here tonight.”
Without a word, Jessica started to cry. She got up from the table, ran to
her room, and shut the door. Her mother followed and put her arm
around Jessica as she lay sobbing on her bed. At first, Jessica did not re
spond to her mother’s quiet questions about what was so upsetting, but
after a few minutes she blurted out, “Every other girl in my class got in
vited but I didn’t. They all hate me! I can tell. They tried to keep this
sleepover birthday party a secret, but I heard them talking about it when
I was in the bathroom and they didn’t know I was there. I heard Shelly
say, ‘You can’t tell Jessica about this, I’ve invited all of you except her.
She just doesn’t fit in.’ And they all said, ‘Yeah, nobody else will want
her there either. It’ll be a lot better without her.’”
This sort of rejection by peers would be difficult for any child, but chil
dren (and some adults) with ADHD tend to get overwhelmed in such sit
uations. Sometimes this is because the child with ADHD is especially
sensitive to rejection. Yet for many with ADHD, the problem is that rejec
tion from peers occurs more quickly and more often because the child with
ADHD may actually be too impatient, too immature, too demanding, too
sensitive to criticism, or too bossy with other children and not as willing to
compromise in working out interpersonal conflicts as most others of simi
lar age. One study obtained peer ratings for 165 children with ADHD ages
7–9 years and did follow-up peer ratings for 6 years. They found that 52% of
those children were rated in the rejected range by their peers, whereas only
1% were rated as having popular status (Hoza et al. 2005).
It can be extremely difficult for parents to find an effective way to
help their child in peer group conflicts without making the situation
worse. They may intervene and talk with the parents of the other chil
dren involved or with the teacher to try to get peer interactions at school
changed. Yet if the other children are confronted by their own parents or
their teacher and punished for rejecting the outcast child or urged to be
friend him or her, those children may comply superficially while subtly
intensifying their rejection or bullying of the outcast, who is now seen as
the tattler who got them into trouble.
Case Example: A 12-year-old whose divorced

parents disagree about his treatment
Jerry’s father brought him to be evaluated for possible ADHD when he
entered sixth grade. He explained that Jerry had been struggling with
reading since third grade, the year that his parents had undergone a bit
ter separation and divorce. Teachers described Jerry as friendly and
bright but also restless and having a lot of difficulty in understanding
and remembering what he read. Jerry’s father, himself a teacher, wanted
to see if Jerry might have ADHD so he could get help before starting
middle school. Jerry’s mother refused to participate in the evaluation be
cause she felt that Jerry didn’t need it. A full clinical evaluation found
that Jerry was a very bright 12-year-old who fully met diagnostic criteria
for ADHD. At the evaluation, Jerry said that he wanted to try treatment
with medication, something that had been quite helpful to one of his
friends. His pediatrician prescribed appropriate medication, but Jerry
then refused to start taking it. He reported that his mother and her new
husband had told him that he did not need medication for ADHD, and
they warned him that ADHD medication would stunt his growth.
Like many other children of divorced parents, and some children of

married parents living together, Jerry was caught in the middle. He
deeply loved and respected both of his parents, but on this issue, and
many other matters, each parent was urging him to do something that
was strongly opposed by the other parent.
Jerry’s father had suffered with ADHD when he was a boy and did
not get diagnosed or treated until he was in college, after he had strug
gled in school for many years. He wanted to protect Jerry from similar
struggles. Jerry’s mother had a brother who had struggled with drug
addiction and dropped out of high school because of it. She was terrified
that Jerry might get addicted to any medication he took for ADHD. She
also had recently married a man who was convinced that medication for
ADHD would stunt Jerry’s physical growth; he was currently one of the
shortest boys in his class. Jerry’s parents shared legal custody, and Jerry
lived with each of his parents on alternating weeks.
Jerry told me that each of his parents had been talking with him end
lessly about how important it was for him to follow the recommenda
tion that he or she was making. He felt that he would enrage and
seriously worry his mother if he began taking the ADHD medication
that she felt could endanger him. If he did not take the medication, Jerry
felt he would be seriously disappointing his father and rejecting some
thing that his father was convinced would be immensely important for
Jerry’s future success in school. Each parent was asking for Jerry’s loy
alty and compliance with his or her own wishes.
I had several meetings with Jerry and both of his parents to try to
help each of them see the bind in which Jerry was caught. I also pro
vided accurate information about how the medications work, explain
ing that medications are often, but not always, effective; that they do not
stunt ultimate growth; and that the risk of problems with addictions is
greater for children with ADHD who are not treated with medications
than for those who are treated. Eventually, we reached agreement from
both parents to start a trial of medication for ADHD treatment while
carefully monitoring its effectiveness and Jerry’s physical development.
Case Example: A 13-year-old who cuts herself

when she gets disappointing grades
Friends of 13-year-old Cindy reported to their middle school advisor
that they were worried about her because she had shown them fresh
scars from several small cuts she had made on her arm with a razor
blade. Her teachers said that Cindy, a girl new to this school, often
seemed tired and somewhat inattentive in class. Her homework was al
ways done well and handed in on time, but her test scores were often
much lower than would be expected from someone who performed so
well on homework assignments. A few teachers wondered if Cindy had
been getting too much help from her mother when doing her home
work. When I met with Cindy’s mother, she told me that Cindy was to
tally independent in doing her homework and worked 3 or 4 hours most
evenings to get it done. She also said that Cindy got very upset when she
got low test grades because she was trying to show her father, who lived
out of state, that she was a smart, hard worker. Her mother was unaware
that Cindy had been cutting herself.
When I met with Cindy and her mother together, I learned that the
self-cutting had begun shortly after Cindy came to this school and usu
ally occurred after Cindy received a low grade on a test. Cindy said that
she had heard about self-cutting from a TV show and decided to try it
one day when she came home from school after receiving an almost fail
ing grade on a test for which she had spent a lot of time studying the
night before. She said that seeing a few drops of her blood after making
a small cut on her arm seemed to take away some of her feelings of sad
ness and shame about doing poorly on the test. Since then, she had re
peated the self-cutting on several other days when she received a low
test score.
As Cindy talked about her difficulties in remembering material she
had read and studied to prepare for tests, it soon became clear that she
was suffering from undiagnosed ADHD, which had not been recog
nized at her previous school. Like many other bright students with
ADHD, she had done very well in elementary school, where most of her
class time was spent with the same teacher. Now, in middle school,
where she had to deal not only with a new school setting but also with
changing classes, multiple teachers, a more challenging curriculum, and
heavier homework demands, her underlying impairments of executive
functions had become more noticeable.
Cindy felt there was a lot at stake with her grades. Her parents had
recently divorced, and her father had moved to take a job a thousand
miles away. He kept in touch with her daily by phone, but much of his
talk with her involved asking her about what homework she was doing
and what grades she was getting. He praised her a lot for good grades
and kept encouraging her to work harder when she got low grades. She
feared that he would be disappointed and, perhaps, lose interest in her if
she did not maintain high grades. That motivated her intense home
work efforts and led to her fearful shame that prompted the self-cutting.
Recognition of this dilemma led to diagnosing and treating Cindy for

her ADHD and also to a series of phone conferences involving Cindy
and both of her parents so they could provide more of the support she
needed.
Case Example: A 15-year old whose parents
battle over his punishment
Don, a 15-year-old high school freshman, had many friends and was es
pecially popular because he was one of the best athletes on the freshman
football team. However, he was not well liked by his teachers. Most of
them found him annoying because he was often argumentative and dis
rupted class with wise guy comments. He tended to score high on tests
but often did not do his homework.
After he got warnings of possible failure in two courses, his mother
asked the teachers for weekly reports and told Don that she would give
him double allowance for each week with a good report. The following
4 weeks brought no improvement in the weekly reports. Don com
plained that the teachers simply disliked him and were always looking
for something to complain about.
At that point, Don’s father called the football coach and insisted he
was taking Don off the football team for the rest of the season. He also
told Don that he would be grounded: no after-school or weekend activ
ities until he produced good reports for at least 4 successive weeks.
Don’s mother protested that his father’s actions were too harsh and
would make things worse. She wanted to take Don to be evaluated for
ADHD because a friend had suggested that as a possible reason for his
problems. His father argued that Don had no problem except for insuf
ficient self-discipline; he feared that ADHD might be used as an excuse
for Don’s laziness.
Parents of children with ADHD often become polarized into ex

treme positions and spend much time and energy accusing one another
of being too harsh or too lax in dealing with their child. One parent may
argue that the child is suffering considerably from the impairments re
lated to ADHD and needs much more support and understanding
rather than confrontation and punishments. The other may argue that
the child needs to be punished promptly for misbehavior or failure to do
assigned tasks so he or she can learn eventually to discipline himself.
Unfortunately, such arguments often lead to each parent taking an
increasingly extreme position in response to the arguments of the other,
diminishing their ability to work together to reach mutual decisions
about how to handle the difficult task of figuring out when to hold the
line and crack down versus when to ease up and lend more support.
Parents faced with these difficulties often benefit from consultation
with a professional who can help them develop a shared, science-based
understanding of ADHD and related problems. This should include an

understanding that individuals with ADHD tend to have a few specific
activities in which they are strongly interested; they are able to focus on
and perform these activities quite well even though they have so much
difficulty in working effectively on most other required tasks. Parents can
also benefit from talking with a professional familiar with ADHD about
how to make reasonable, constructive use of parental incentives, re
wards, and punitive consequences as well as effective treatments to help
their son or daughter with ADHD to develop adequate self-discipline.
Case Example: A 14-year-old who struggles

with her homework after losing mother’s help
Joanne had just completed her first semester of high school. Her grades
had dropped to barely passing, much lower than the honor roll grades
she had been getting throughout elementary and middle school. When
her mother brought Joanne to see me, she was angry because Joanne had
hidden her report card for more than a week because she felt ashamed of
the big drop in her grades. Her mother was also worried because Joanne
had been crying a lot and was repeatedly saying that she felt really stu
pid and was uncertain whether she would ever graduate from high
school. Joanne had been taking a long-acting medicine for ADHD that
had been helpful since fifth grade, when she was diagnosed by her pe
diatrician. Also, for years, Joanne had gotten a lot of help with home
work from her mother every day after school; she was cared for at the
time by her grandmother while her mother worked as a nurse on the
night shift. Since September, that homework help had stopped because
her mother was now required to work a 3:00 to 11:00 P.M. shift. Mean
while, Joanne had been selected to be a cheerleader at her high school
and had to attend practice after school each day. As we discussed this in
my office, Joanne was crying because she had disappointed her mother
and grandmother. Joanne’s mother was also upset; she felt that her hav
ing to work the afternoon shift was ruining her daughter’s education,
but as a single mother, she felt she had no choice.
The transition from elementary school to middle school is difficult

for many students; adapting to high school is usually much more diffi
cult, especially for students with ADHD. In elementary school, students
are usually with one teacher for most of each day. That teacher can pro
vide structure and continuity to assist students with self-management
and organization. Usually, middle school brings increased demands for
self-management because of having multiple teachers and changing
from one classroom to another. High school imposes even greater de
mands for self-management because of an increased number of class
changes throughout each day. High school also escalates the need for or
ganizing homework and longer-term assignments. For children who
struggle with executive functions, as those with ADHD do, the transi
tion into middle school and then into high school is usually much more
difficult.
The high school transition is often problematic for parents too be
cause communication between parents and teachers tends to be more
limited in that setting. Unless the school provides and maintains an ex
ceptionally effective Web site monitoring system, parents are unable to
monitor what assignments have been given in each subject, what the
specific requirements are, when each assignment is due, and whether
their son or daughter is getting them done adequately and in on time.
Many high school students quickly learn to manage their work ade
quately, but, like Joanne, many with ADHD struggle considerably, es
pecially during their freshman year.
Joanne clearly cared a lot about doing a good job with her school
work, but the loss of her mother’s daily support for organizing and
completing homework presented her with tasks for which she was not
prepared. She was accustomed to meeting with her mother each after
noon for more than an hour to review what homework needed to be
done and to work under her mother’s close supervision and encourag
ing support. Her mother’s unavailability during those important hours
was a significant loss.
Joanne was proud of being chosen to be a cheerleader for her school,
and she enjoyed attending the practice sessions every day after school.
However, this meant that Joanne now needed to do her homework after
dinner rather than immediately after school each day. One effect of this
change in routine was that the ADHD medication Joanne had found
helpful for many years wore off before she got home to do her home
work. We arranged for her to get a short-acting booster dose of her
ADHD medication to take in late afternoon so it would provide cover
age for doing homework after dinner but not interfere with her getting
to sleep in the evening. This helped to improve her focus, but the med
ication could not replace the help Joanne had previously been receiving
from her mother.
Case Example: An 18-year-old who fails
in his first semester of college
Alan was diagnosed with ADHD and Asperger’s syndrome when he

was in third grade. With appropriate medication for his ADHD and
strong support from his parents, Alan earned good grades in school and
participated successfully in Boy Scouts and in the robotics club at his
high school. Alan was proud that he had been admitted to the engineer
ing program at his state university, but he felt more than a little nervous
when it was time to pack up his stuff and move into the dorm on the uni
versity campus 2 hours away from his home. He was quite shy, except
with family and a few friends he had known since elementary school.
When he arrived on campus, Alan attended his classes but mostly kept
to himself in his room, with the exception of getting meals and using the
bathroom. He struggled with writing papers, but he was too fearful to
seek help from the writing clinic. He got poor grades on many of his tests
because he did not feel comfortable asking any other students to study
with him and was terrified of going to open office hours where his pro
fessors were available for individual consultations with students. Alan
was ashamed of his declining grades and kept telling his parents that
college was difficult but he was doing OK. He did not let them know
how much difficulty he was actually having until his first semester was
over and he received failing grades in four of his five courses.
Alan came with his parents for a consultation with me shortly after he
received his semester grades. It quickly became clear that he was an ex
tremely bright young man who continued to suffer from ADHD and also
from severe social anxiety and some characteristics of Asperger’s syn
drome. After considering alternatives, Alan and his parents decided that
he would request an immediate medical leave from the university and
return to living at home while he began a medication trial, engaged in
psychotherapy with me, and enrolled in a couple of engineering-related
courses in the local community college.
I had several joint meetings with Alan and his parents to address
Alan’s intense shame over his failure at college, his guilt over having
kept his difficulties secret from his parents until it was too late to salvage
his semester, and his intense fears about whether he would ever be able
to return to the university and be successful. His parents felt guilty that
they had not been more active in keeping track of how Alan was doing;
they also resented the fact that they had paid a very sizable tuition for a
semester that yielded no academic credits. Another difficult issue was
how Alan and his parents would explain to neighbors, extended family,
and friends why he was now living at home and going to the commu
nity college when all of them had understood that he had been enjoying
a successful first semester of his freshman year at the university.
Alan’s treatment included SSRI medication to address his intense so
cial anxiety, stimulant medication to alleviate his ADHD symptoms,
and cognitive-behavioral treatment to learn to develop the social skills
needed to interact with faculty, staff, and other students at the commu
nity college. He needed coaching to plan how to approach classmates to
form small study groups for course work review and projects in both of
his classes. We discussed how to choose students he might feel comfort
able approaching and what words he could use to initiate conversation,
how to learn their names, and how to get contact information. With that
support, he gradually discovered that he was able to make successful
contact with a few students in each of his classes to work together on
problem sets, to review for tests and exams, and sometimes to have a
good time with. Alan continued at the community college for the sum
mer program and then decided to take an additional year at the com
munity college. He did well in that year, both academically and socially;
this led to successfully resuming his studies and living in the dorm at
the university campus.
Case Example: A 22-year-old in conflict with

his girlfriend and her reaction to his ADHD
George had been seeing me intermittently for treatment of his ADHD
since he was a freshman in high school. He was now 22 years old and
was home from college for the summer; he called to ask if he could bring
his girlfriend, Debbie, with him for a consultation with me. When they
arrived, George explained that he and Debbie had been dating each
other exclusively for almost a year, and she wanted to come with him to
talk with me about ADHD. When I asked what they wanted to discuss
with me, Debbie pulled a list out of her purse and began to ask one ques
tion after another about ADHD.
Her first question was “How much do people with ADHD change as
they get older?” I asked her to give me an idea of what kind of changes
she was wondering about. She said, “Do they get more mature, more re
sponsible about doing what they say they will do? Do they get better at
showing up on time when you’re planning to go someplace together?
Do they get better at listening to what other people are trying to say?” I
asked George what he thought was Debbie’s reason for wanting to get
answers to these questions. He responded, “She wants to know if my
ADHD problems will ever get better than they are now.”
I explained that there is no one pattern of behavior change that is true
for everyone with ADHD. Sometimes ADHD characteristics get better as
one gets older, sometimes they get worse in response to life experiences
and demands, while other ADHD characteristics may persist for a life
time—much the same as characteristics of anyone else. Debbie was not
happy with that answer. She emphasized that she was now 22 years old
and needed to know if this relationship with George was going to work
out for her over the long term. I asked if she felt that George currently
had any desirable characteristics that she enjoyed and appreciated. She
mentioned that she liked his great sense of humor and his spontaneity,
that he often came up with interesting comments and fun things to do.
She acknowledged that he was very bright and did well in most of his
courses. But then she said emphatically, “But if I’m going to stick with
him, there are a lot of things he will need to change!”
George asked her, “What are you talking about? What is it that you
feel I have to change in order for you to want to stick with me?” She re
sponded in a scolding tone, “You know exactly what I’m talking about—
I tell you about this same stuff all the time. You’re always late when
you’re supposed to meet me, and there’ve been some times when you’ve
totally forgotten what we planned to do. Lots of times when I’m trying
to talk with you, you’re not really paying any attention, you’re just mess
ing with your phone. Sometimes you go for days without even sending
me a text, you get too busy with your schoolwork or just hanging out
with your guy friends. And when I try to tell you what I need, you just
try to change the subject or go do something else. You don’t really an
swer or have a decent conversation to resolve things.”
Debbie then turned to me and asked, “Can’t you change his medi
cine so he can be better about these things?” George answered before I
could respond. He said, “What do you think Doc is going to do, get me
some medicine that will totally get rid of my ADHD problems and make
me some kind of robot that will do everything the way you want me to?
Does it count at all that I love you? Is the way I am now really that bad?
You’re not exactly perfect all the time yourself.”
As we neared the end of the appointment time, I told Debbie and

George that I thought they had a lot more talking to do to sort out what
each of them was appreciating and feeling frustrated by in the other. I
also cautioned them that in any intimate relationship, it’s important to
recognize that while people can change over time, for better or for
worse, it’s likely to be frustrating if someone commits to a long-term re
lationship with the expectation that the other person has to change in
major ways in order to be an acceptable partner. That is a recipe for dis
appointment, whether the issue is ADHD or anything else. I also men
tioned that if one is looking for a perfect partner, it is likely to be a long
wait.
Case Example: A divorced woman immobilized

by undiagnosed ADHD and shame
Karen was 48 years old and had been divorced from her husband for 3 years
when she came for an initial consultation with me because she had read
Smart but Stuck (Brown 2014) and felt that it described her. Karen ex
plained that she struggled through high school and then attended four
different colleges before she completed her degree. She worked in sales
for 10 years before she married. She then had two sons, now teenagers,
and had been caring for them full-time since her divorce. Over the previ
ous year, she had also been caring for her mother, who was quite ill and
who died from cancer a few months before our first consultation. Karen
reported that she had been treated with several different medications and
had also tried a variety of homeopathic medicines for her long-standing
chronic depression and anxiety. She had not found any of them to be
helpful for reducing her constant feeling of being overwhelmed and dis
organized. “My house is a mess with a lot of clutter and huge piles of pa
perwork. I’m always late for everything. I spend a lot of time on the
computer just surfing, and I can’t stop myself to get to the grocery store to
get something to cook for dinner and have ready when the boys get home
from school and team practice. And in all this, I’m a perfectionist. I feel
stuck, especially over the past few years, unable to do what I need to do to
take care of my kids and myself. I’m ashamed of my house, of my life, and
of my parenting. It’s never been this bad before.”
Karen, a very intelligent woman, was staggering under a huge bur

den of self-criticism and hopelessness, as well as her grief over the recent
loss of her mother. As we began to work together, it became clear that her
self-criticism was a long-standing problem. Though quite bright, she
had struggled with schoolwork from her earliest years of school. She
had been raised in a well-to-do family with high expectations. Her par
ents and teachers were puzzled as to why a girl who seemed quite bright
and quick to grasp ideas in discussion had so much difficulty in com
pleting assignments and passing examinations. Her siblings had been
quite successful in competitive colleges while she transferred from one
college to another until she finally completed her degree in the fourth
university she attended. Her chronic anxiety and mounting depression
were recognized, but treatment for these did not address her undiag
nosed ADHD. Criticism from parents, teachers, and siblings had fueled
her self-criticism for most of her life.
Karen’s marriage compounded her difficulties. Her husband strug
gled with multiple problems, including excessive drinking and what she
later learned was severe ADHD. Both of their sons also had ADHD with
some behavioral problems; this was not recognized until their adolescence
and intensified the difficulties the parents faced during the 14 years before
they separated.
After she experienced some incapacitating side effects from medica
tions prescribed for her anxiety and depression, Karen gave up on pre
scription medications and sought help from a homeopathic practitioner.
She felt only slight improvement from the homeopathic she was given,
but she appreciated that those supplements had not caused significant
adverse effects in her apparently sensitive body chemistry. Neverthe
less, none of the remedies she had been given provided any help in al
leviating her substantial executive function impairments, which were
the primary focus of her frustration and shame.
Karen emphasized that her problems with executive functions had
worsened considerably in recent years. Those years coincided with the
onset of menopause. Many women who have ADHD find that their
ADHD symptoms worsen as they enter menopause, and some women
who have never had significant ADHD symptoms earlier in their life be
gin to suffer from executive function impairments quite similar to ADHD

as they enter menopause. This makes sense because estrogen is one of the
primary modulators of dopamine in the female brain. Dopamine is the
neurotransmitter chemical that facilitates communication within neural
networks of the brain that support executive functions of the brain. For
some, not all, women, the reduction of estrogen that occurs in meno
pause brings an initial onset of executive function impairments or, as in
the experience of Karen, the estrogen loss can substantially worsen pre
existing ADHD impairments that have been present for many years, es
pecially if their ADHD is not adequately treated. Our research group has
published three scientific journal articles (Epperson et al. 2011, 2015;
Shanmugan et al. 2017) describing our research demonstrating that
ADHD medications can be helpful for some women in alleviating these
executive function impairments of menopause.
Effective treatment for Karen required a very cautious trial of stim
ulant medication for her impairments related to ADHD; she responded
well to a very small dose, considerably less than is needed by most
adults; this helped to alleviate her ADHD-related impairments signifi
cantly. Once her ADHD medications were stabilized, we tried an anti
depressant, also in a very small dose, which her very sensitive body
chemistry could tolerate. Gradually, that medication helped to reduce
her chronic anxiety and depressive symptoms. However, medications
alone were not sufficient. More than anything else, Karen needed and
made good use of intensive psychotherapy in which she slowly worked
through her immobilizing self-criticism and improved her ability to
manage aspects of her daily life that for many years had felt unmanage
able to her.
One additional aspect of treatment that proved beneficial to Karen
was getting both of her sons engaged in treatment for their persisting
ADHD. Parents with ADHD often struggle intensely with the challenges
of parenting their children, especially if one or more of those children
has ADHD. In such situations, adequate treatment for ADHD-related
impairments of both the parent and the child or children can be helpful
for all.
Case Example: A married couple on the brink

of divorce because of the husband’s
untreated ADHD
Martha, 41 years old, came with her husband for a consultation with me
a few days after she had told him that she wanted a divorce to end their
16 years of marriage. She said, “I’m fed up with too much giving and not
enough getting back. I feel like I’m raising not just our two children, but
three! My husband, Greg, does a good enough job at work, and he’s a
good provider, but at home he’s just like one of the kids. I have to struggle
to get him up and off to work every morning, and I have to remind him to
get off the computer every night so he won’t stay up playing video games
until 2:00 or 3:00 A.M. I’ve given up on his taking care of our monthly bills
because he never pays them on time. We were getting threatening letters
and calls from creditors because he forgot to pay. There was enough
money in the bank, and he said he would take care of it.
“Once in a while he’ll start a project at home, but then he never fin
ishes it. For 2 years, we’ve had bare two-by-fours in our bedroom where
he says he’s going to put in new plasterboard. Mostly when he’s home,
he’s on the computer or watching sports on TV. He says he’s going to
come to the kids’ sports events, but then he forgets to show up. When I
try to talk with him, he listens for maybe a minute or two, then he’s drift
ing off talking about something else. He’s not a heavy drinker and he’s
not abusive, but he is neglectful. I’ve been married to him for 16 years,
but all that time I’ve been neglected by this man. He seems to need a
mother to take care of him day by day more than he needs or wants a
wife.”
I expected that Greg would respond to his wife’s complaints with
anger, but he didn’t. He cried. He acknowledged his frequent forgetful
ness and frequent neglect of tasks, events, and concerns that were im
portant to his wife and to his children. He then said, “You’re right! I
make a lot of promises to you and the kids that I don’t follow through on.
And I do depend on you to keep me organized and to remind me about
what needs to be done and when to do it. I’ve never been good at stuff
like that. When I was a kid, all the way through high school, my mother
had to hassle me every day to get me up in the morning. If she hadn’t, I
would have slept through school. I’ve never been able to get myself up
with an alarm clock. And she had to keep pressuring and reminding me
to get my homework and chores done. Even though I wanted to, I just
couldn’t manage that stuff myself. You help me with so much, and
you’re not even mean about it. I just don’t know if I can change the way
I’ve been for so many years. I don’t know if it’s something that can be
changed.”
Greg clearly had ADHD that had never been diagnosed or treated.
He willingly agreed to try a regimen of medication to alleviate his
chronic ADHD problems. After a couple of dosage adjustments, it was
quite helpful to him. But that did not fix all the problems in their mar
riage. We spent several months of weekly sessions together to try to
identify specific changes that this couple needed to make to protect their
marriage and improve the quality of life for themselves and their chil
dren.
The problems of this couple were not limited to Martha’s complaints.
Gradually, Greg began to air some of his frustrations with her. He re
sented Martha speaking to him often in condescending tones, as though

he were no different from their children. He realized that he sometimes
deliberately frustrated Martha by ignoring her requests because he felt
she was picking on him too much, undermining his children’s respect
for him and his respect for himself. Gradually, Greg made changes in
how he managed his responsibilities at home, and slowly, Martha made
changes in how she dealt with Greg. Together they planned weekly
times for the two of them to go out for dinner or a movie. Eventually,
they also resumed their sexual life together, an aspect of their marriage
that had long been avoided. Both had begun to grow more fully into a
mutual adult relationship, rather than a mutual reenactment of Greg’s
patterns of interacting with his mother when his ADHD had been un
recognized and untreated.
Summary
The new model of ADHD described in this book emphasizes two ways in
which emotions are often problematic for persons with ADHD: 1) exec
utive function impairments often impair their ability to modulate emo
tional expression and 2) working memory impairments often bias their
motivations in ways that lead to maladaptive decision making and prob
lematic behaviors as a result of not considering the larger context or likely
future consequences.
Examples in this chapter illustrate just a small number of the many
ways emotions are entwined in the daily life experiences of not only in
dividuals with ADHD but also other members of their family, class
mates, friends, persons they date, persons they marry, and children they
care for. Additional examples are provided and discussed in my earlier
book, Smart but Stuck: Emotions in Teens and Adults with ADHD (Brown
2014). It should be noted, however, that many of these emotional dy
namics are not consciously recognized unless those affected are pro
vided assistance in examining the complexity of their emotions, which
are often quite subtle and interactive.
10
Practical Aspects
of Medication
Treatments for ADHD
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
(ADHD) is essentially a problem in the chemical dynamics of the brain,
and the most effective treatment for ADHD is usually medication.
However, medication for ADHD cures nothing. It is not like an antibi
otic that may cure a strep throat. It is more like my eyeglasses. I have a
problem with my eyes that makes it hard for me to read typewriter-size
print; those letters look totally blurry to me. When I put my eyeglasses
on, I can read those letters as well as almost anyone else. When I take
my glasses off, I’m right back where I started—unable to read the blurry
letters. The eyeglasses do not cure my vision problem, and medications
do not cure ADHD.
Although medications do not cure ADHD, for about 8 of 10 people
with ADHD, approved medications, properly fine-tuned, can signifi
cantly improve their ADHD impairments. For some, the improvement
is huge; for others, improvement is not huge, but it is substantial. For
some, it helps a little but not very much, and for 2 of 10, the medications
customarily used for ADHD either don’t work at all or cause side effects
that the person should not or does not want to put up with.
171
How Does Medication

for ADHD Work?
In Chapter 6 (“How ADHD Develops, Sometimes Gets Worse, and Some
times Improves”), I offered a basic description of how messages related to
executive functions are communicated within the brain. Here I review
that information while providing some additional information relevant
to ADHD medications. When they work, medications for ADHD help to
improve communication within and between complex networks within
the brain that function as the brain’s management system.
This vast and complex system is contained within the brain, an or
gan that weighs only about 2 and a half pounds and is about the size of
a large grapefruit. Within the brain are multiple networks of more than
100 billion neurons, “gray matter,” each of which is only one-millionth
of an inch across, visible only with a powerful microscope. Connections
between regions of neurons in the brain are provided by networks of
“white matter” fibers, which if stretched out from an individual’s brain
would be about 150,000–175,000 kilometers long.
For this management system to work, countless messages have to be
transmitted via low-voltage electrical impulses that travel at lightning
speed from one neuron to another. These neurons do not directly touch
each other; there are gaps between their connection points; those gaps are
called synapses. When one of these messages reaches a connection point, it
must jump that gap like the spark of a spark plug and then hit receptors on
the other side of the gap. If enough receptors are hit fast enough, the mes
sage goes across and moves on in fractions of a second to the place in the
network where it needs to go. If the connection with the receptors at the
junction is not sufficient, it quickly fizzles without crossing the junction.
To get across these junctions, the sending neuron needs to quickly re
lease tiny microdots of a chemical made in the neuron. These chemicals
are transmitters for the messages. Most of the neurons that control exec
utive functions operate on either dopamine or norepinephrine, two of
the more than 50 neurotransmitter chemicals made in the brain. Frac
tions of a second after the transmitter chemical microdots are released,
tiny cells on the sending side of the gap (transporters) work as tiny vac
uum cleaners to quickly suck up those chemicals and repackage them so
they can be ready to carry new messages across. This transmission pro
cess is amazingly fast: in one-thousandth of a second. as many as 12 mes
sages can be carried across the gap.
It should be noted, however, that most of the countless communica
tions that go on within the human brain are not tied to any one single
Practical Aspects of Medication Treatments for ADHD 173
neuron. Most intrabrain messages are carried by large ensembles of

neurons joined transiently to convey related bits of information across
networks of countless synapses (Hanson et al. 2012; Nicolelis et al.
1997a, 1997b). Messages arriving at these networks of synapses are not
like isolated dots or dashes of Morse code; they are more like cascades of
electronic impulses carrying richly variegated tones of complex music
generated by multiple instruments.
For persons with ADHD, there are two ways in which the transmis
sion process can be impaired. The sending neurons may not release
strong enough signals to hit enough receptors to make an effective con
nection, or the sending cell’s “vacuum cleaner” cells may suck the trans
mitter chemical back too quickly before adequate connections can be
made.
Stimulant medications for ADHD such as methylphenidate and am
phetamine do their job at the connection points by slowing the action of
the vacuum cleaner cells so the transmitter chemical gets to sit on the re
ceptors just fractions of a second longer, but enough to get a more ade
quate connection. Some of these medications also cause a slight increase
in the amount of transmitter chemical that gets released initially.
The rate and persistence of signaling across the gap to the receptors
reflects the importance of that specific message to that person’s brain at
that moment. This weighting might be compared to the difference be
tween a single knock on a door and repeated knocking on a door to con
vey urgency or continuing importance of that particular message.
Neural messages perceived by the brain as having lower priority—less
interesting or less threatening—travel with weaker signals conveyed by
a slower rate and less persistence.
The entire process of setting signal strength is incredibly fast, and it
is unconscious. Multiple complex networks in the brain, many directly
connected to a hub called the amygdala, quickly process and prioritize
relevant unconscious, emotion-laden memories from past experiences
and previous learning to determine how interesting or threatening any
specific perception seems to be to that person in the context of the situ
ation at that moment. This is the brain’s “googling,” which impacts mo
tivation, as is described in Chapter 5 (“How ADHD Impacts ‘Brain
Googling’ for Motivations”).
It appears that persons with ADHD, much of the time but not always,
tend to have more difficulty than others in processing the importance of
many tasks they are faced with. As is described in Chapter 2 (“A New
Model of ADHD”), individuals with ADHD all tend to have a few activ
ities or tasks for which they are able to focus and manage themselves
very well, even though for many other tasks and activities of daily life
they are not able to mobilize themselves to focus and function effectively.
Medications for ADHD, when they work, help those with ADHD to ac
tivate themselves and manage themselves more effectively during that
part of the day when the medication is active in their body. While active,
medication for ADHD can help to improve communication between
neurons in ways that can significantly improve the person’s abilities for
self-management on a more consistent basis, even for tasks that are not
especially interesting or threatening.
Medications approved by the U.S. Food and Drug Administration
(FDA) for treatment of ADHD include stimulant medications such as
methylphenidate and amphetamine and some other medications that
are not stimulants. Methylphenidate has been used for ADHD since the
mid-1950s. The ADHD medication best known to most people is Ritalin,
which is one brand name for methylphenidate. Other brand names for
methylphenidate include Metadate, Concerta, Focalin, and Daytrana.
Amphetamines have been available since 1937; they currently include
Dexedrine, Adderall, and Vyvanse. Hundreds of peer-reviewed re
search studies on the use of stimulant medications have been published.
Tables 10–1, 10–2, and 10–3 list names and characteristics of currently
approved medications for treatment of ADHD and show which are
available in immediate-release and/or longer-acting formulations.
Nonstimulant medications include atomoxetine, guanfacine, and
clonidine. They are different from the stimulant medications in that they
do not act primarily on the dopamine system of the brain. Atomoxetine
(brand name Strattera), like the stimulants, is considered a first-line
treatment for ADHD. It acts primarily on the norepinephrine system
and indirectly on the dopamine system. Atomoxetine is not usually as
powerful as the stimulants in improving inattention symptoms, but it
sometimes works when stimulant medications are ineffective or cause
too many side effects. More than 30 research studies have demonstrated
the usefulness of atomoxetine for children, adolescents, and adults not
only for ADHD but also for ADHD accompanied by anxiety, tics, and
some other comorbid problems. Atomoxetine, unlike the stimulants, is
dosed according to the individual’s weight, starting with a stipulated
small dose and then gradually increasing over several weeks. Often it is
4–6 weeks before it is possible to determine how effective the medica
tion will be for that person.
Other nonstimulant medications currently approved for treatment
of ADHD are guanfacine (Intuniv) and clonidine (Kapvay); both are α2
adrenergic agonists that act primarily on the norepinephrine system
and have been used to reduce excessively high blood pressure in adults.
These nonstimulants may be helpful not only for ADHD symptoms but
TABLE 10–1. Amphetamines approved for the treatment of attention-deficit hyperactivity disorder
(ADHD)
Trade name, Approximate Ages
(year FDA approved), Usual dosage range duration of action approved for
Duration of action formulation Available strengths (mg) (start–maximum) (mg) (hours) ADHD
Shorter-acting Adderall [G] 5, 7.5, 10, 12.5, 15, 20, 30 3–5 years: 2.5 qam to 20 bid 6–8 3+
medications (1960) 6–17 years: 5 qam to 20 bid
Tablet 18+: 5 qam to 20 bid
Dexedrine 5, 10 3–5 years: 2.5 qam to 20 bid 3–5 3–16
(1976) 6–16 years: 5 qam to 20 bid
Tablet
Evekeo 5, 10 3–5 years: 2.5 qam to 20 bid 3–5 6–17
(2012) 6–16 years: 5 qam to 20 bid
Tablet
ProCentra [G] 5 mg/5 mL 5–20 bid 3–5 3–16
(2008)
Oral solution
Zenzedi 2.5, 5, 7.5, 10, 15, 20, 30 3–5 years: 2.5 qam to 20 bid 3–5 3–16
Practical Aspects of Medication Treatments for ADHD
(2013) 6–16 years: 5 qam to 20 bid

Tablet
Longer-acting Adderall XR [G] 5, 10, 15, 20, 25, 30 6–12 years: 5–30 qam 8–12 6+
medications (2001) 13–17 years: 10–40 qam
Capsule 18+: 20–60 qam
175
TABLE 10–1. Amphetamines approved for the treatment of attention-deficit hyperactivity disorder
(ADHD) (continued)
Trade name, Approximate Ages
(year FDA approved), Usual dosage range duration of action approved for
Duration of action formulation Available strengths (mg) (start–maximum) (mg) (hours) ADHD
Adzenys XR-ODT 3.1, 6.3, 9.4, 12.5, 15.7, 6–12 years: 6.3–18.8 qam 11–14 6+
(2016) 18.8 13–17 years: 6.3–12.5 qam
Tablet 18+: 12.5–18.8 qam
Dexedrine Spansule [G] 5, 10, 15 5 qam to 20 bid 10–14 6+
(1976)
Capsule
Dyanavel XR 2.5 mg/1 mL to 6–17 years: 2.5–20 qam 10–14 6+
(2015) 20 mg/8 mL
Oral solution
Vyvanse 10, 20, 30, 40, 50, 60, 70 30–70 qam 8–12 6–17, adults
(2007)
Capsule
Note. FDA=U.S. Food and Drug Administration; G=generic; ODT=orally disintegrating tablet; XR=extended release.
Source. Adapted from Puzantian T, Carlat D: Medication Fact Book, 3rd Edition. Newburyport, MA, Carlat Publishing, 2016. Used with permission.

TABLE 10–2. Methylphenidates approved for the treatment of attention-deficit hyperactivity disorder
(ADHD)
Trade name, Usual dosage range Approximate Ages
(year FDA approved), (start–maximum) duration of action approved for
Duration of action formulation Available strengths (mg) (mg) (hours) ADHD
Shorter-acting Focalin [G]

2.5, 5, 10 2.5–10 bid 3–4 6–17
medications Dexmethylphenidate
(2001)
Tab (2x potent vs. MPH)
Methylin CT [G]
5, 10, 20 2.5 bid to 20 tid 3–4 6–17, adults
(2003)
Chewable tablet
Methylin [G]
5 mg/5 mL; 10 mg/5 mL 2.5 bid to 20 tid 3–4 6–17, adults
(2002)
Liquid
Ritalin [G]
5, 10, 20 2.5 bid to 20 tid 3–4 6–17, adults
(1955)
IR tablet
Longer-acting Aptensio XR
10, 15, 20, 30, 40, 50, 60 10–60 qam 8–12 6+
medications (2015)
Capsule (40% IR, 60% DR)
177
(ADHD) (continued)
Longer-acting Concerta [G] 18, 27, 36, 54 18–72 qam 10–16 6–12, adults
medications (2000)
(continued) Capsule (22% IR, 78% DR)
Daytrana Patch 10, 15, 20, 30 10–30 qam & remove 8–12 6+, adults
(2006) after 9 hours
CR transdermal patch
Focalin XR [G] 5, 10, 15, 20, 25, 30, 35, 40 6–17 years: 8–12 6–17, adults
Dexmethylphenidate XR 5–30 qam;
(2005) 18+ years:
Capsule (50% IR, 50% DR) 10–40 qam
Metadate CD [G] 10, 20, 30, 40, 50, 60 20–60 qam 8–12 6+
(2001)
Methylin ER [G] 10, 20 20–60 qam 4–8 6+
(2000)
Hydrophilic polymer tablet

(ADHD) (continued)
Longer-acting Quillichew ER 20, 30, 40 20–60 qam 8–12 6+

medications (2015)
(continued) Chewable tablet (30% IR, 70% ER)
Quillivant XR 25 mg/5 mL 20–60 qam 8–12 6+
(2012)
Liquid (20% IR, 80% ER)
Ritalin LA [G] 10, 20, 30, 40, 50, 60 20–60 qam 8–12 6+
(2002)
Note. CR= controlled release; CT=chewable tablet; DR=delayed release; ER=extended release; FDA=U.S. Food and Drug Administration; G=generic;
IR=immediate release; LA=long acting; MPH=methylphenidate.
179
TABLE 10–3. Nonstimulants approved for the treatment of
attention-deficit hyperactivity disorder (ADHD)
Trade name Approximate
(year FDA approved) Available Usual dosage range duration of action Ages
Class Formulation strengths (mg) (start–maximum) (hours) approved for ADHD
α2-Adrenergic Intuniv [G] 1, 2, 3, 4 1–4 mg qd. Do not increase 24 6–17

agonist (guanfacine ER) faster than 1 mg/week.
(2009) Adolescents 7 mg qd max.
ER tablet
Kapvay [G] 0.1, 0.2 0.1 mg qhs. Increase by 0.1 12–16 6–17
(clonidine XR) mg qd weekly & give
(2009) divided bid; max 0.4 mg qd.
ER tablet
Selective norepineph- Strattera 10, 18, 25, 40, <70 kg: start 0.5 mg/kg; 24 6–17: max daily dose of
rine reuptake (atomoxetine) 60, 80, 100 target 1.2 mg/kg, 70 mg; 18+: max daily
inhibitor (2002) max 1.4 mg/kg. dose of 100 mg
Capsule If >70 kg, 40–100 mg.
Note. ER= extended release; G=generic; XR=extended release.

also for excessive irritability, aggression, difficulty in falling asleep, and

tics (vocal and/or motor). Side effects of these nonstimulant medica
tions may include excessive tiredness, stomachaches, nausea, and vom
iting. Usually, but not always, these side effects improve as the person’s
body becomes accustomed to the medication. Kapvay and Intuniv have
both been approved by the FDA for use in combination with stimulants
for treatment of ADHD.
Dosing for guanfacine (Intuniv) usually begins with 1 mg given at
bedtime, and then, if needed, the dose is increased cautiously, no more
than 1 mg at a time, with the individual taking a given dosage for at least
1 week before any increase to a maximum dosage of 4 mg/day. Clonidine
(Kapvay) is usually started at 0.1 mg at bedtime and then, if needed, in
creased to 0.2 mg or a maximum dosage of 0.3 mg/day.
Either methylphenidate or an amphetamine is usually the first
choice for treatment. If the first medication is ineffective, then usually
the other will be tried. If neither stimulant works or if both cause exces
sive side effects, the next choice is usually atomoxetine. However, some
patients do better starting with atomoxetine if there is reason to believe
that the individual may be especially sensitive to stimulants, has a his
tory of tics, has a recent history of stimulant abuse, or has a strong per
sonal preference.
More detailed, but readily understandable, information about medica
tions for ADHD is available in Straight Talk About Psychiatric Medications for
Kids, 4th Edition (Wilens and Hammerness 2016), and Stahl’s Illustrated
Attention Deficit Hyperactivity Disorder (Stahl and Mignon 2011).
What Influences the Effectiveness

of ADHD Medication?
One factor that influences how well medication for ADHD works for a
given person is dosing. Many medications can be prescribed simply by
age or weight—little children need very small amounts and big people
need much larger doses. For stimulants, the medications most often
used for ADHD, it does not work that way. Most small children do re
spond best to very small doses, but there are a few little children with
ADHD whose bodies do not respond to the small doses that usually
work for children of their size; those few may respond best and without
any side effects to the larger doses customarily used for much bigger
children or adults.
Likewise, most bigger and heavier people usually respond best to
more substantial doses of stimulants. However, there are a few very big
people who respond best to very small doses of stimulants, doses simi
lar to what would usually be given to a preschooler.
Because age and weight are not an adequate guide to what dose of
stimulant works best for someone with ADHD, it is usually best to be
gin with a very minimal dose and then, if there are no significant bene
fits and no adverse effects, to increase every 3–5 days until a dose is
found that is effective without causing undesirable side effects.
This process of adjusting the dose of a stimulant medication is essen
tially a search for that “sweet spot” between too much and too little. If a
person is taking too little medication for ADHD, it is useless; you might
just as well be taking breath mints. If you are taking too much stimulant
medication you are likely to be feeling too “wired” or jittery, as though
you’ve consumed way too much coffee. Or you may be feeling too irri
table, much more likely to get angry over little frustrations that would
not usually bother you (Arnsten and Li 2005; Arnsten and Pliszka 2011).
Becoming too serious is one additional problem that may be caused
by a dose of stimulant that is too high for an individual. Individuals may
lose their “sparkle,” their spontaneity, their sense of humor. They may
be able to focus well for tasks, but they do not feel much like interacting
with others. They do not feel like their regular self.
These side effects that can come from taking a dose of stimulant that
is too high for the person are usually very temporary; they generally dis
appear as the medication wears off later in the day.
Can ADHD Medication Benefit

Older Adults?
Although there has been increasing recognition that many adults age 50
or older experience ADHD (Das et al. 2012, 2015; Guldberg-Kjär and Jo
hansson 2015; Michielsen et al. 2015a, 2015b), there is, thus far, little re
search on the experience of older adults with ADHD medications.
Lensing et al. (2015) reported on a study of 149 adults age 50 years or
older (average age 55.8 years) who were diagnosed with ADHD at an
average age of 50 years. Sixty-one percent of those participants had a
child who had been diagnosed with ADHD, and 26% had a grandchild
with an ADHD diagnosis.
In the Lensing et al. (2015) sample, 87.9% reported having been
treated with medication for ADHD, most with stimulants. Of those who
had tried the medications, 36% stopped using the medication, whereas
64% found medications helpful and were currently continuing use.
Those currently treated with medication for ADHD reported that their
attention was improved compared with 10 years ago, and they tended
to be employed, whereas those who had never taken medication or who
had stopped taking medication did not report improved attention and
were less likely to be employed. Those who continued taking medica
tion also reported better self-efficacy—better ability to manage their life
than those who did not continue medication treatment.
The mean dosages of medications used were 54.1 mg/day for meth
ylphenidate and 29.5 mg/day for amphetamines. A review by Torgersen
et al. (2016) concluded that many patients age 50 years or more who had
ADHD-related impairments experienced beneficial effects from treat
ment with ADHD medications. However, Torgersen et al. (2016) em
phasized the importance of an adequate physical examination prior to
starting such medications in this older population and urged starting
with low doses and very gradual titration. It is also important to be alert
to possible interactions between ADHD medications and other medica
tions an older patient may be taking for various medical or psychiatric
difficulties.
Fitting ADHD Medications

to a Person’s Schedule
Even if a person is getting a dose of ADHD medication that works well,
there is another problem: fitting the medication into the person’s daily
schedule. Most important is making certain that the medication is not
seriously disrupting the person’s eating or sleeping. Stimulant medica
tions can significantly reduce a person’s appetite. Typically, the medica
tion doesn’t change the person’s appetite for breakfast. Depending on
the specific medication, it can take from 30 minutes to an hour and a half
for the effects of the pill to really kick in. However, stimulant medication
certainly can reduce a person’s appetite for lunch and possibly also for
dinner. Usually, this effect wears off within a few days or a few weeks of
regular use. Occasionally, reduced appetite continues for more than a
few weeks; in that case, some adjustment of dose or timing may resolve
the difficulty.
Many people with ADHD have chronic problems falling asleep even
prior to taking any medication. For them, ADHD medication taken
close to bedtime may help them stop ruminating and focus better on
falling asleep. However, for most people taking stimulants, there is need
for an interval between when their ADHD medication wears off and
when they are able to go to sleep. The necessary interval may be just an
hour or it may need to be 4–6 hours after the medication has worn off.
Because of individual differences in how long a particular medication

takes to wear off and how much time the patient needs to relax into
sleep, the clinician monitoring medication response may need to work
with the patient over a few weeks to determine what schedule will work
best.
It is not uncommon for anyone taking stimulant medication for the
first time to have considerable difficulty falling asleep for the first few
days. Usually, this can be prevented by avoiding taking any stimulant,
especially a long-acting stimulant, in midafternoon or later. There are
many individual differences in how medication may affect sleep. Some
people need 2–6 hours or more after their last dose of a stimulant has
worn off before they can begin to fall asleep. Others are able to fall
asleep readily less than an hour after taking a dose of stimulant.
Many individuals with ADHD report having difficulty not only with
getting to sleep but also with awakening. Often parents report that the
most difficult part of their day is getting their children with ADHD
awake and getting them to complete their morning routine and out the
door in time to catch their bus or ride to school each morning. This pro
cess is not easy in any household, but for children with ADHD, the pro
cess of awakening, getting out of bed, completing morning hygiene,
getting dressed, eating breakfast, and gathering homework, books, and
belongings to leave for school presents increased challenges due to slug
gish awakening, dawdling, forgetfulness, morning irritability, and diffi
culty keeping track of the passage of time. These processes are typically
problematic not only for young children, but also for adolescents and
even parents themselves, especially if multiple members of the family
have ADHD.
Even if persons with ADHD are taking helpful medications during
the day, most ADHD medications, even immediate-release formula
tions, do not actually kick in quickly enough to be of much help for the
morning routine, even when taken immediately on awakening. Some
parents attempt to counter these problems by awakening their child
with ADHD an hour before he or she actually needs to get up and giving
the child a dose of immediate-release stimulant and a sip of water while
he or she remains in bed. This can work if the child can get back to sleep
for the remaining hour and then awaken after the medication has had a
chance to kick in.
Similar problems are faced by college students or other adults living
alone who do not have anyone to awaken them at the earlier hour so
early medication can help them get themselves up and effectively
launched on time for classes or work. Some are able before they go to
bed at night to set out their morning dose and a glass of water at their
bedside table and set an alarm clock to awaken them an hour before
they need to get up; they set a different alarm clock across the room to
awaken them at the time they actually need to get up. However, many
individuals with ADHD have chronic difficulty remembering to make
these preparations at bedtime.
Many people find that longer-acting stimulants, medications like
Vyvanse, Concerta, Adderall XR, Focalin XR, and generic equivalents,
work well for them during the day once they kick in. These longer-lasting
formulations reduce the need to take multiple doses over the course of
the day, and they often have fewer ups and downs in their coverage.
However, there is a lot of variability from one person to another in how
long the longer-lasting stimulants actually work.
Published estimates claim that some particular long-lasting medica
tions work effectively for 12–14 hours; for other long-lasting medica
tions, estimates are 8–10 hours or 6–8 hours of effectiveness. These
estimates are all averages based on trials with carefully selected sam
ples. For some patients, the medication lasts significantly longer than
the reported average. For other patients, that same medication may lose
effectiveness in less than half of the reported average time.
These differences in duration of action can make a big difference in
planning adequate coverage of medication for any given individual pa
tient. For example, our group found that 60% of adolescents and adults
being treated with a long-acting stimulant with a reported 10- to 16-hour
duration of action needed a booster dose of short-acting stimulant in
midafternoon to late afternoon to cover additional hours to successfully
manage tasks in late afternoon and early evening.
When considering addition of short-acting medications to extend
the duration of action of longer-acting stimulants, it is important for the
prescriber to keep in mind that for most longer-acting medications, the
potency of the extended dose at any time over the course of the medi
cation’s action is only one-half of the face value of the longer-acting for
mulation. For example, a 20-mg dose of Adderall XR does not provide
20 mg of coverage throughout its duration of action. It provides 10 mg of
coverage for the first few hours and then another 10 mg of coverage for
the following few hours. In contrast, the immediate-release version of
Adderall 10 mg releases the full 10 mg at the outset. This needs to be
taken into account when planning combined use of longer-acting and
shorter-acting stimulant medications.
Another problem with fitting stimulant medications to an individ
ual’s daily schedule is time of onset. Some short-acting stimulants kick in
within about 30 minutes after the pill is swallowed. Some longer-acting
stimulants produce very few benefits until 60–90 minutes after ingestion.
Here is an example of how these variables may work. A 16-year-old

high school student must get up at 6:00 A.M. to catch his bus to school at
6:30 A.M.; his classes start at 7:15 A.M. If he takes a long-acting stimulant
at 6:15 A.M., it may not even start to kick in for him each day until 7:45 or
8 A.M. and may not reach optimal strength until an hour or two later. For
that student, it works best to take a short-acting stimulant at 6:15 A.M. at
the same time as the longer-acting stimulant. The short-acting medica
tion helps the patient as a “jump start,” while the longer-acting capsule
gradually launches itself to cover the rest of the school day.
This same 16-year-old student is an athlete who plays on his school’s
teams for three seasons: football, basketball, and lacrosse. Throughout the
school year, he does not get home from sports practice until about 6:00 or
6:30 P.M. He then showers, eats dinner, and, while tired, faces an average
of 2 hours of homework, sometimes more. His ADHD medication for
school has lost effectiveness by about 3:00 P.M., leaving him with no cov
erage for doing his homework. He finds that taking a small booster dose
of short-acting stimulant as soon as he gets home, even before showering
and eating dinner, gives him the coverage he needs to get his homework
done before it wears off, and it does not interfere with getting to sleep.
Many adults with ADHD also have problems getting adequate cov
erage with their ADHD medications. Some who leave home at 7:00 A.M.
to commute to work want to take a long-acting medication so they do
not have to remember to take doses several times during the day. Yet a
long-acting medication taken at 7:00 A.M. may wear off as early as 1:00 or
2:00 P.M., leaving no coverage for the rest of their workday or their tasks
like preparing meals, helping children with doing homework and get
ting ready for bed, or doing paperwork they need at work the next day.
An adult in this situation might benefit from taking a second dose of
the long-acting medication in early afternoon to midafternoon. In this
case, the second dose of the long-acting stimulant probably should be a
bit lower than the initial morning dose because there is likely to be some
residual of the morning dose still active in the body, even if it is not suf
ficient to maintain adequate symptom control.
How Can Stimulant Medications
Be Fine-Tuned for a Specific Person?
Given the individual variabilities in body sensitivity that influence

what dose of ADHD medication is likely to be most effective and what
timing of dosing is likely to provide the best coverage for the individ
ual’s daily schedule, careful inquiry is necessary to fine-tune for an op
timally effective medication regimen. The treating clinician needs to

take time to ask not just “How is this medicine working for you?” It is
necessary to take the time to ask more detailed questions about specific
responses and to link these to time of day.
The first thing to ask about and write down is whether the patient has
been experiencing any adverse effects, anything that he or she finds un
comfortable or dislikes (e.g., headache, stomachache, difficulties with
sleep or appetite). If any are reported, it is important to ask the time of day
that a problem was noticed, how long it lasted, and when it went away.
Was it greater in the morning, afternoon, or evening? Did the problem
stay the same over the course of the day, or did it start and then stop? Did
the adverse effect occur only for the first few days of taking the medicine,
or did it persist and get better or worse over a series of days?
After inquiring about possible adverse effects, it is time to ask whether
any benefits or other changes were noticed. This can be done using a
scale from 1 to 10, where 1 indicates that the person was unable to focus
and was unable to carry out necessary tasks and where 10 indicates that
the person was quite well focused and able to work reasonably well. It is
usually helpful to begin by asking how the person would rate himself or
herself on that scale if he or she has had no medication. Once that base
line has been obtained, the clinician can inquire about where on the
scale the person felt himself or herself to be at various times during the
day (e.g., 8:00 A.M., 10:00 A.M., 1:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M.).
When this information is linked with information about what doses
of medication were taken at particular times of the day, the clinician can
help the patient develop a profile of how quickly the medication kicks in
and at what time it seems to lose effectiveness. This can then be com
pared with information about times of eating and sleeping and what
tasks and demands the person has at various points in the day. By inte
grating these various bits of information, the clinician can tailor a plan
to optimize medication dosing to safeguard eating and sleeping sched
ules and to provide optimal coverage at those times of the day when
ADHD medication is most needed.
How Can the Impact of ADHD

Medications on Anxiety and
Moods Be Assessed?
When assessing effects of ADHD medications on an individual’s func
tioning, it is important to consider the impact of the medication on the
person’s anxiety and moods. Although current DSM-5 (American Psy
chiatric Association 2013) diagnostic criteria include no mention of

problems with emotions as a symptom of ADHD, many individuals
with ADHD report that they struggle frequently with excessive anxiety,
irritability, depression, or moodiness (Brown 2014).
For some individuals, ADHD medications significantly improve
such emotional difficulties. Some individuals who were chronically
anxious or irritable prior to any ADHD treatment report that stimulant
medication helps them feel more calm and less anxious or irritable than
ever before. By strengthening executive functioning, the stimulant may
improve “top-down” control of their unsettling emotions.
Posner et al. (2014) reviewed the reported evidence that stimulants
may be helpful in reducing emotional lability for children and adults with
ADHD. Sinita and Coghill (2014) reported on the emerging consensus that
stimulant medications can be helpful in improving emotional dysregula
tion and lability as well as oppositional and conduct problems often asso
ciated with ADHD. They also noted that stimulant medications may
improve outcomes in persons with treatment-resistant depression and may
reduce negative symptoms and improve cognitive performance in persons
with schizophrenia. More research is needed to verify these reports.
However, it is also true that some individuals who take stimulant
medications for ADHD experience an initial onset or intensification of
anxiety, irritability, or dysthymic feelings that may be related to use of
that medication. If so, the clinician should ask for details about how of
ten and when these emotional difficulties occur, whether they arise only
intermittently or are more consistent, and at what point in the day they
tend to begin and to remit. If such emotional difficulties do not arise
during the time the medication is active but do occur as it is wearing off,
the emotional reaction may be an aspect of rebound, which is described
in a subsequent section of this chapter, “What Is Rebound and How Can
You Tell If the Medication Dose Is Too High?”
If the emotional difficulties arise during the period when the medica
tion is active and then improve as it wears off, the problem may be that the
dose is too high for that patient at that time. The difficulty may be allevi
ated by reducing the dose. If dose reduction is helpful without seriously
compromising the positive effects of the medication, the reduced dose
should be continued. If the dose reduction results in the medication losing
its effectiveness for ADHD-related impairments, it may be necessary to
discontinue that medication and try an alternative medication.
For example, if the patient experiences significant improvement in
ADHD-related impairments when taking a longer-acting stimulant but
continues to feel too anxious or irritable taking the dose that works best in
reducing symptoms, it may be helpful to reduce the dose of the longer
acting stimulant and augment with a small dose of shorter-acting stimu

lant in the morning to help “jump-start” the patient’s functioning while
using the reduced dose of the longer-acting stimulant to provide coverage
for the remainder of the day. An alternative might be switching from an
amphetamine to methylphenidate or vice versa to see if a different form of
stimulant will produce adequate results without adverse emotional ef
fects. Other options might be to discontinue the longer-acting formulation
and use only immediate-release stimulants on a two-times-daily or three
times-daily regimen; to reduce the dose of stimulant and combine with a
small dose of atomoxetine or guanfacine; and to discontinue the stimulant
and try a nonstimulant such as atomoxetine (Brown 2004).
Does Stimulant Medication

Need to Be Taken on the
Same Schedule Every Day?
To be effective, some medications need to be taken daily to maintain a
specific medication level in the bloodstream. That is not true of stimu
lants. Whatever stimulant medication is taken today is pretty much
gone from the body by the next day. If a day of medication is missed, it
is similar to a day where I do not have my eyeglasses. I simply do not
have the beneficial effects of the glasses during that day. Having worn
them the previous day does not provide any benefit the following day.
Often students taking medications for ADHD and their parents ques
tion whether they should take their stimulants on weekends and school
vacations. I usually ask patients to take their stimulants 7 days a week
while we are trying to find an effective dose. After an effective dosing reg
imen has been found, the students and parents can then determine
whether they want the medication to be taken every day or to take it only
on days when they will be in classes, have homework to do, or have some
other activity for which they feel the medication will be helpful.
Sometimes, there will be a reason to minimize medication intake
whenever possible. For example, a small number of children and adult
patients continue to have significantly diminished appetite while taking
stimulant medications, even after they have been taking that medica
tion for many months. If they tend to be underweight, it may be helpful
for them to refrain from taking their stimulant medication on any day
that it is not needed for school or schoolwork. That may allow them to
eat more heartily to compensate for their usually diminished appetite.
I see many high school and college athletes with ADHD. They tend to
differ on whether they want to take their ADHD medication to cover the
hours they are engaged in practice or games. About 50% like to take their
ADHD medications when playing their sport. It helps them improve their
ability to sustain focus and planning while they are playing so they do not
experience mind wandering or poor recall of the coach’s directions dur
ing the game. The remaining 50% prefer not to take their ADHD medica
tion when playing their sport because they feel it causes them to think too
much, to hesitate in making their moves as spontaneously as may be
needed. The only way I know to decide who should or should not take
their medication while playing their sport is to have them try it both ways
and then let me know which way seems to work better for them.
What Is Rebound and How Can

You Tell If the Medication Dose
Is Too High?
There are three signs that suggest the dose of a stimulant medication may
be too high. Each of these applies for the time the medication is supposed to
be working and then diminishes as the dose wears off: 1) the person feels
too “wired,” restless, or “revved up” or as if he or she is racing; 2) the person
feels much more irritable than usual, annoyed by little frustrations far more
than usual; 3) the person is too serious, losing his or her “sparkle” or spon
taneity, able to focus well perhaps but not feeling like his or her regular self.
If any of these patterns occurs over several days during the time the medi
cation is expected to be active and then diminishes as the medicine wears
off, there is a strong probability that the medication dose is too high for that
individual or that this is just not a good medication for that person.
However, if the person does not have any of those difficulties during
the time the medication is expected to be active and he or she does have
one of those problems later in the day when the medication is expected to
be wearing off, that is likely to be a rebound. It does not mean the dose is
too high because that reaction would have been seen during the time the
medication was supposed to be active. Instead, such a response during the
hours the medication is expected to be wearing off indicates a rebound.
Rebound is a term used to describe the person’s “crashing” as the
medication is wearing off. Usually, this means the medication is drop
ping off too quickly. Often this can be corrected by administering a small
booster dose of the short-acting form of that medication about 30 min
utes before the rebound has been occurring. This smooths the drop-off
curve to create a slower, more gradual decline from the earlier dose.
There are two reasons for using a booster dose: 1) to prevent a rebound
of excessive restlessness, irritability, or lack of spontaneity and 2) to ex

tend the duration of the medication’s action for a few more hours.
How Can You Tell If an ADHD

Medication Is Working Effectively?
If a stimulant medication is working effectively to alleviate ADHD im
pairments, there should be a noticeable improvement in executive func
tions (described in Chapter 2) during the time the medication is active.
Those improvements would be expected to diminish as the medication
wears off, just as vision improvements provided by wearing eyeglasses or
contact lenses are lost when the glasses or lenses are removed. Medica
tions do not produce improvements before they kick in, a time period that
can be as short as 30 minutes or as long as an hour and a half following in
gestion. If a stimulant medication produces noticeable changes at a given
dose level and then, a few days or a week later, does not produce those
improvements, it is likely that the dose is almost at the right level but not
quite there yet. A slight increase in dose should restore the benefits.
Some children and adults are very much aware of when their stim
ulant medication kicks in and when it wears off. Other patients report
that they do not feel any different while the medication is supposed to
be working, even though parents, teachers, coworkers, or friends report
that they observe quite a noticeable difference while the medication is
active. Sometimes patients will report that they do not feel any differ
ence in their mood while the medication is in their bloodstream, but
they do notice that they are getting more work done, reading more care
fully, or remembering information more easily and consistently than
usual. The critical test of the ADHD medication’s effectiveness is not so
much whether patients feel a dramatic change of mood; the test is
whether patients are able to deploy their executive functions more ef
fectively while taking medication than they can without the medication.
What Does It Mean If an ADHD

Medication Seems Helpful and
Then Loses Effectiveness?
While the dose of an ADHD medication is initially being tried and ad
justed, there may be a period of a few days or a week or two when the
patient reports or seems to show significant improvement in executive
functions and then soon loses that beneficial response. If that is the case,
the most likely explanation is that the dose used during that time was al
most—but not quite—at the optimal point for that person. It is as
though the novelty of the drug’s effect on the brain wore off, and those
networks returned to their usual level of functioning. Often a slight in
crease in dose will restore the previously noticed effectiveness.
If a person has been taking an ADHD medication for a longer time—
months or years—and then notices that the medication has gradually lost
its earlier effectiveness, there may be a need to increase the dose a bit to
see if that will restore effectiveness. This may become necessary because
the person is under more stress than usual, is encountering more chal
lenges than previously, is not getting enough sleep, is in a growth spurt, is
fighting an infection, or is taking an additional drug that interferes with
the ADHD medication (e.g., using too much marijuana), or other changes
in the body or daily life may be altering the threshold of efficacy. How
ever, it is important to inquire into possible factors that may be producing
the change before escalating the dose. Some other intervention may be
more helpful. However, it is also true that occasionally, for some patients,
a medication may simply lose its effectiveness after a period of prolonged
benefit for no identifiable reason. This type of unexplained “poop out”
can occur with almost any type of medication, including antidepressants,
antihistamines, and many other medications unrelated to ADHD. In such
situations, it is sometimes necessary to try a different ADHD medication,
which might work more effectively. If after a “vacation” from the earlier
medication it is restarted, effectiveness may return.
It should also be noted, however, that sometimes an ADHD medica
tion that has been effective for a fairly long time at a stable dose may be
gin to cause the person to feel uncomfortably restless or much too
focused or too irritable over many days without any apparent reason.
Sometimes what is needed in that situation is a slight reduction of the
dose. This is not uncommon among children or adolescents, who some
times need a smaller dose of medication as they get older.
Is a Generic Version of an ADHD

Medication Less Effective?
Many generic formulations of medications work just as well for most
people as do the more expensive brand-name medications. FDA rules
require that the generic’s maximum concentration of the active drug in
gredient in the blood must not fall more than 20% below or increase
more than 25% above that of the brand-name drug it is expected to re
place (Dunne et al. 2013; Eban 2013).
For many users, such a 20%–25% variance makes no difference in the

effectiveness of the medication. However, for some users, that differ
ence could substantially reduce effectiveness or increase side effects.
Unfortunately, patients do not come with labels to indicate who will or
will not be affected by such a difference.
There are also other factors, not included in the FDA regulations, that
may affect how the generic formulation affects a person compared with
the brand-name drug. There may be differences in how quickly or slowly
the medication is released. There may also be differences in nonactive
components such as the ingredients in the packing inside the pill or its
coating. All of these factors may impact some users of the medication.
In 2016, there were three different pharmaceutical companies produc
ing and selling pills identified as generic equivalents of Concerta
(Thomas 2015). The FDA found that the products being sold by two of
those companies were not equivalent to brand-name Concerta. The
agency instructed those two manufacturers to improve their product or
take it off the market. For many months, neither of those actions were
taken, and many patients complained that the “Concerta” they had been
taking had suddenly lost effectiveness or was causing unprecedented
side effects. Often those patients or their parents were not even aware that
a generic medication had been substituted. Even if they became aware of
the problem, many did not know how to find out which brand of generic
their pharmacy was using to fill their prescription or when a change from
one generic version to another had been made by the pharmacy in the
pharmacy’s efforts to obtain the most advantageous price for itself.
If a medication for ADHD (or anything else) seems suddenly to have
lost its effectiveness, the patient should notify the clinician and also check
with his or her pharmacy to ask whether a generic medication was sub
stituted for the drug or whether a different brand of generic is now being
used to fill the prescription. Sometimes one pharmacy in a community is
buying and using one generic version of a particular drug, while another
pharmacy is utilizing a generic produced by a different manufacturer that
may be more or less effective for any given patient.
What Are the Risks of Drinking

Alcohol While Taking
ADHD Medications?
To avoid the risks of drinking alcohol while taking ADHD medications,
the best advice is to avoid consuming alcohol while an ADHD medica
tion is in your bloodstream. Sometimes people deliberately take stimu
lant medication while drinking alcohol because they feel it will keep
them more alert while partying. The problem with this is that the stim
ulant medication is likely to make it more difficult for a person to rec
ognize when he or she has had too much alcohol or is getting too tired
and needs to stop. This can lead to excessive drinking, which can put a
person at risk of not only an intense hangover but also more serious
problems due to impaired judgment or high-risk behavior or possible
alcohol poisoning, which can be fatal.
Many who take stimulant medications early in the day will refrain
from taking any more stimulant in the afternoon or evening; they will
drink only a moderate amount of alcohol later in the evening when the
level of stimulant in their bloodstream is reduced. However, given the
wide variations in how quickly or slowly various individuals clear stim
ulants out of their bloodstream, anyone using ADHD medication who
wants to drink alcohol should discuss this with his or her clinician to get
personalized advice that also includes consideration of any other med
ications the individual may be taking that could complicate his or her
reaction to alcohol.
Many different kinds of medications can significantly alter how al
cohol affects a person’s body. While in the bloodstream, medications
used for anxiety, depression, sleep, pain, and other problems can poten
tiate the effects of drinking alcohol. Depending on the level of the spe
cific medication in the bloodstream at the time, one drink can double or
triple the bodily effects of any alcohol-containing drink without the
drinker realizing what is happening. Many medications when com
bined with alcohol can also cause cardiovascular difficulties, which can
range from mild to serious. The National Institute on Drug Abuse has
published a booklet that describes what types of medications can cause
such problems (National Institute on Alcohol Abuse and Alcoholism
2003).
How Does Using Marijuana

Affect a Person Who Is Taking
ADHD Medications?
Marijuana provides relaxation for many people, but depending on the
strength of the tetrahydrocannabinol (THC) and the amount taken in, it
can also substantially intensify ADHD impairments of executive func
tion such as alertness, getting started on tasks, sustaining focus, and uti
lizing working memory.
Marijuana can also block the useful effects of ADHD medications,

especially if one is smoking or otherwise consuming it in significant
quantities on a regular basis. This is true not only during the period the
individual feels high. Depending on how much is consumed and how
frequently, some effects of THC persist much longer. Because THC is
stored in fat cells, it is excreted slowly from the body over days or
weeks; some effects of THC persist and become chronic if frequent use is
continued. One of the major problems of heavier or very frequent use is
that the person gradually tends to not give a damn about many things
he or she really does need to give a damn about.
Does a Person Taking an ADHD

Medication Need to Take It for
His or Her Life?
Almost anyone taking medication for ADHD can stop it at any time.
Only if a person has been abusing the medication by taking extremely
large doses, or dosing with excessive frequency, or consuming much
more than would ever be appropriately prescribed over a prolonged pe
riod is there significant likelihood of becoming addicted and having
trouble stopping the medication. Otherwise, for most people, stopping
ADHD medication is like stopping the wearing of eyeglasses. People
are likely to notice the loss of the benefits of the medication, especially
over the first week or two, but then they are most likely to return to the
baseline of functioning they had before starting the medication.
However, there are some individuals who are particularly vulnerable
to addiction who escalate their dosing pattern and become tolerant to
very high doses of stimulant, more than would usually be prescribed.
Any person who has a history of stimulant abuse should be carefully
evaluated and may do best on a nonstimulant medication for ADHD or
on a very limited and closely monitored regimen of longer-acting stimu
lants, such as Vyvanse, which have less potential for abuse than shorter
acting stimulants.
Some persons take medication for their ADHD for just several
months or a couple of years and then do not need it anymore. This does
not mean that the medication has cured their ADHD-related impair
ments. It may be that their continuing brain development has pro
gressed enough to manage executive functions more effectively without
needing the medication anymore. Or it may mean that the person no
longer needs the level of improvement in executive functions that the
medication provided. For example, some who needed medication for

their ADHD while in school may not need it after they are out of school
and engaged in activities that fit better with their natural interests, per
haps a job that excites and interests them, or when they no longer are re
quired to do work that involves reading, writing, or other tasks that are
more challenging to their native abilities, or if they have a secretary or
other assistant who takes care of tasks for which they have little interest
or facility.
What Evidence Is There That

Stimulant Medications Improve
Symptoms of ADHD?
Stimulant medications have been used to treat ADHD symptoms for de
cades. There is a very large body of research that has tested the effective
ness of these medications. Three main types of research have been
reported:
• Imaging studies to observe changes in brain functioning and connec

tivity when a person with ADHD is taking medication or a placebo
• Structured experiments on specific ADHD-related functions in which
one group of children or adults with ADHD was tested doing a spe
cific task while taking medication compared with a matched group
tested on the same task while taking placebo
• Clinical trials that tested whether children or adults carefully diag
nosed with ADHD show reduced severity of the symptoms of
ADHD while taking a particular medication when compared with a
matched group of others with ADHD who are taking a placebo or a
different ADHD medication
Imaging studies have demonstrated improvement in activation of

specific brain regions that are not functioning effectively in children or
adults with ADHD (Epstein et al. 2007; Konrad et al. 2007; Pliszka et al.
2007). Other imaging studies have shown improvement in activation of
attention and motivational control brain networks (Rubia et al. 2009;
Volkow et al. 2004) and normalization of brain circuits that prevent ex
cessive distractibility (Rubia et al. 2011). Additional studies demon
strated improved functional connectivity for working memory of
individuals taking stimulant medication (Wong and Stevens 2012) in
brain circuits that help to suppress excessive distractibility (Peterson et
al. 2009) and in dopamine signaling to reduce inattention, hyperactivity,

and impulsivity (Volkow et al. 2012).
Experimental studies have shown that while taking stimulant med
ication, children with ADHD showed improved classroom behavior
(Abikoff and Gittelman 1985). Other studies showed that boys with
ADHD worked more quickly and efficiently on arithmetic problems
(Carlson et al. 1991) and that they were more willing to keep trying on
frustrating tasks when taking medication (Milich et al. 1991). Children
taking medication also showed improved visual-spatial memory (Be
dard et al. 2004), improved ability to inhibit themselves on a stop-signal
task (Bedard et al. 2003), and improved motivation to perform well on a
variety of executive function tasks (Chelonis et al. 2011).
A systematic meta-analysis review of 23 double-blind, placebo
controlled studies of stimulant medication used with children and ado
lescents found very positive results across the sample groups (Faraone
and Buitelaar 2010). The data analysis indicated robust, statistically sig
nificant effects for all stimulant medication treatments assessed.
A similar meta-analysis of effect sizes for 18 published studies of stim
ulant and nonstimulant medication treatment of adults with ADHD found
similarly high levels of effectiveness for stimulants and lower effect sizes
for treatment with nonstimulants (Faraone and Glatt 2010). A study that
compared effectiveness of stimulant versus nonstimulant medications
for ADHD in youths also found that stimulants had very high levels of
effectiveness, whereas nonstimulant medications were also effective but
not with such a high margin as stimulants (Faraone et al. 2006b). How
ever, it is important to keep in mind that these comparisons are based on
the data of group averages. Within such groups, there are likely to be
many who respond equally well to either type of ADHD medication,
and some who respond better to nonstimulants than to stimulants.
What Risks Are Involved in Using

Approved Stimulant Medications
for ADHD Treatment?
No medication is without some risks. No one can ever promise that any
particular medication given to any specific person is 100% guaranteed
to have no adverse effects. Some medications, even widely used medi
cations such as antibiotics used to treat infections or analgesics used to
treat fever or headaches, can be associated with serious, potentially fatal
adverse reactions in a very small number of persons who take them.
Such reactions are extremely rare and generally occur only in individu
als whose health is seriously impaired, but they do occasionally occur.
However, when medications are administered within accepted guide
lines to basically healthy individuals, adverse effects from medications
approved for treatment of ADHD involve relatively few risks.
The active ingredients of most medications currently approved to
treat ADHD have been in use for decades by very large numbers of chil
dren, adolescents, and adults. Amphetamine has been available since
the 1930s, and methylphenidate was introduced in the 1950s. The first
reports of the beneficial effects of amphetamine on learning and behav
ior of children were provided in 1937 by Bradley (1937), who discovered
these benefits accidentally in his research with emotionally and behav
iorally disturbed children.
Initially, these medications were widely used by adults as a treatment
for depression and to induce weight loss. They were officially issued to and
used by the American, British, German, and Japanese soldiers, sailors, and
airplane crews during the Second World War and are still officially issued
to some pilots in the U.S. Air Force to help them stay alert on long flights.
Both methylphenidate and amphetamines are controlled by the U.S.
government and most other governments in the same way opiate pain
medications are controlled; this is because, when misused, they have the
potential for abuse when administered in excessive doses or when ad
ministered in other than oral modalities. In the 1940s, there were numer
ous reports of stimulants being abused as treatments for weight loss.
That is no longer considered an appropriate use of stimulants.
The common side effects of stimulants are not persistent or danger
ous. It is not unusual for patients starting these medications to report
some difficulty with headache, stomachache, reduced appetite, and/or
falling asleep (Aagaard and Hansen 2011). Generally, such reactions are
not severe, tend to be quite transient, and usually respond to adjustment
of dose and/or timing. Some adverse reactions occurred because the
starting dose prescribed was too high for that individual. As mentioned
in the section “What Influences the Effectiveness of ADHD Medica
tion?” there is wide variation among patients in all age groups regard
ing what dose is likely to be the most effective.
Those considering use of ADHD medication for their children or
themselves are often concerned about the potential for more serious ad
verse effects such as heart attack or stroke, growth delays, or the possibil
ity of the child eventually becoming addicted to the ADHD medication or
later getting addicted to some illicit drug. Research has addressed each of
those concerns.
A number of studies have investigated large samples of children and

adults to determine whether use of medications for ADHD might in
crease an individual’s risk of heart attack, stroke, or other serious car
diovascular problems. Studies have compared samples of thousands to
several hundreds of thousands of children from preschool through ad
olescence who were treated with ADHD medications with children who
were never treated with such medications (Cooper et al. 2011; Olfson et
al. 2012). Results provided no evidence for increased risk of cardiovas
cular problems among those treated with ADHD medications. Another
study of more than 400,000 adults found that ADHD medications were
not associated with any increased risk of cardiovascular problems in
adults if taken as prescribed (Habel et al. 2011).
Some parents worry that treatment of their child with stimulant
medications is likely to stunt their child’s growth. A longitudinal study
followed into early adulthood a group of children taking stimulant
medication for ADHD and a matched group of children who did not
have ADHD. Most of the children taking medication were treated with
the medication for about 8 years. Results showed no evidence that stim
ulant medication was associated with any deficits in growth outcomes
at follow-up in adulthood (Biederman et al. 2010b).
However, there is some evidence from a review of studies that some,
not most, children taking medication for ADHD are slightly delayed in
reaching their full height (Faraone et al. 2008; Swanson et al. 2007a,
2007b). Most of those delays are minor and transient, involving differ
ences of 1 centimeter or less, relative to predicted height for age, differ
ences that almost always disappear in later childhood or adolescence.
Nevertheless, monitoring of growth in height and weight should be
done while any child or adolescent is being treated with medication for
ADHD. If a child or teenager is exceptionally small for his or her age,
possible reasons for the delay should be investigated, and consideration
should be given to modification of the treatment plan.
Many parents, aware that stimulant medications are controlled by
the government to prevent abuse, worry that if their child is treated with
stimulants, that medication might cause him or her in adolescence or
later to become addicted to stimulants or to some illicit drug. Actually,
the risk of a child with ADHD eventually developing a substance use
disorder is significantly greater than for others of similar age if that child
is not treated with medication for ADHD than when the child receives
ADHD medication treatment (Charach et al. 2011; Wilens et al. 2011).
Treatment with stimulant medication seems to have a protective effect
against adolescent substance abuse. It does not guarantee that the child
will never become addicted to alcohol or another drug, but it tends to re
duce that risk to a level comparable to that for children without ADHD.
In considering any medical treatment for any disorder, the impor
tant question is, Are the risks of using this treatment for the diagnosed
problem greater or less than the risks of not using the treatment? As de
scribed in Chapter 4 (“Ways ADHD Can Impair Functioning at Various
Age Levels”) and other parts of this book, the risks associated with ADHD
are often quite substantial and may increase with age:
• Preschoolers with significant ADHD are more likely to get injured

(Dalsgaard et al. 2015a), to have more difficulty in getting along with
peers and family members, and to have trouble mastering basic skills
that most others of the same age are learning.
• School-age children with ADHD are likely to have more difficulty in
learning academic skills for reading, writing, and math, in getting
homework done, in keeping track of belongings, and in developing
and maintaining friendships with others of comparable age.
• Adolescents with ADHD are more likely to struggle with schoolwork
and less likely to graduate from high school, less likely to manage
their sleep and health adequately, more likely to engage in risky be
haviors including illicit drug use and risky driving, and less likely to
develop and execute a realistic plan for after high school and beyond.
• Young adults with ADHD are less likely to complete their education/
training to prepare for a career, less likely to find and maintain employ
ment for an adequate income, more likely to struggle with managing
money, and less likely to develop and sustain satisfying relationships
with friends and potential partners.
• Adults with ADHD are less likely to sustain employment to provide
ongoing support for self and any dependents, less likely to develop
satisfying relationships with friends and/or a partner, less likely to
be able to provide adequate care and resources for any children, and
less likely to manage health care and insurance for self and depen
dents.
Medication treatment for ADHD is certainly not a guarantee that an

individual with ADHD will not experience some of these difficulties
due to impairments of executive function, but for many, though not all,
carefully managed medication treatment may significantly reduce the
risks that untreated or inadequately treated ADHD is likely to involve.
Summary
This chapter begins with the assertion that ADHD is essentially a prob
lem of the chemical dynamics of the brain and that the most effective
treatment for ADHD is usually medication. A description of how these
medications work in the brain is provided. It is noted that medication
does not cure ADHD, although for about 80% of children, adolescents,
and adults, approved medication, properly fine-tuned, can alleviate
their ADHD impairments during the hours it is active. Tables list char
acteristics and usual dosages of medications currently approved by the
FDA for treatment of ADHD.
The bulk of the chapter then presents practical information on fac
tors that may influence the effectiveness of medications for ADHD for
various individuals: how a medication regimen can be tailored to a
given individual, how various side effects can be addressed, how to tell
if a dose is too high, how to assess whether a medication is working for
a specific person, and how a clinician should respond if a medication
seems to lose its effectiveness. Answers to a number of other questions
that are frequently asked by clinicians and patients are also provided.
The chapter concludes with a summary of scientific research on the risks
and benefits of medications for ADHD.
11
Practical Aspects
of Nonmedication
Interventions
for ADHD
IN THIS CHAPTER, I PRESENT A WIDE VARIETY

of nonmedication interventions for the treatment of persons with atten
tion-deficit/hyperactivity (ADHD). Education and guidance for parents
and the processes of collaboration and accommodation in educational
settings are explored. Sections on supportive therapy and individual
ADHD coaching are included along with both print and online re
sources that persons with ADHD and their families, partners, and
friends can access to understand and grapple with the symptoms of this
disorder.
Education of Patients and Families

About ADHD and Its Treatments
One of the most helpful and important interventions for patients who
have ADHD and for their families is providing them understandable
and accurate education about ADHD—what it is and what it isn’t. Very
203
few of the individuals who seek consultation or evaluation for ADHD

are without some understanding of the disorder. Their information may
be quite extensive and accurate; it may be partially correct but not
clearly understood; or it may be grossly inaccurate, although strongly
believed. Before trying to give anyone new information about ADHD, it
is important to get some idea of what the person already knows, or
thinks he or she knows, and how willing he or she is to take in new in
formation about ADHD.
Some patients have obtained information from Web sites, confer
ences, books, or magazine articles or from their physicians or other
medical or mental health providers. Others have learned about ADHD
by observing or talking with family members, friends, or others who are
successfully or unsuccessfully living with ADHD. Sometimes the infor
mation the person has obtained is richly detailed and quite accurate.
Sometimes it is quite anecdotal and impressionistic. However, many in
dividuals come with very limited information or grossly mistaken as
sumptions about ADHD.
It is important for the clinician and other mental health professionals
who seek to help the person with ADHD to begin by finding out and
taking into account what the person already knows or believes about
ADHD. In our clinic, this begins at the outset of the initial evaluation.
We start by asking why the patient or parents decided to come at this
particular time rather than earlier or sometime later. We invite a descrip
tion of what specific problems have been noticed, how long they have
been going on, and what has already been done to try to address the
problems. Usually, we do not try to correct misunderstandings about
ADHD at this point. The initial task is to learn what the patient and fam
ily are concerned about and what they are hoping the consultation will
do for them.
Later in the interview, after sufficient background and history infor
mation has been gathered, we take some time to explain that many
changes have occurred in our understanding of ADHD over recent
years, based on facts that have been learned from recent scientific re
search. As is detailed in Chapter 8 (“Assessing Children, Teenagers, and
Adults for ADHD”), we then describe our understanding of ADHD us
ing the six-factor model presented in Chapter 2 (“A New Model of
ADHD”). In doing this, we try to use many brief examples of typical
problems of individuals with ADHD similar to those included in Chap
ter 2. This is not a lengthy lecture, but an interactive conversation. After
each section of the model has been briefly described, we stop and ask
the patient and family to tell us how much the description and examples
we have just offered fit or do not fit the experiences of this particular pa
Practical Aspects of Nonmedication Interventions for ADHD 205
tient. This approach is designed not only to describe the new model of
ADHD but also to function as a way to gather more information about
the degree of fit between current difficulties of this particular patient
and the current scientific understanding of ADHD and/or other disor
ders.
In concluding an initial consultation, we generally offer the patient
and family a brief oral summary of our impressions from what we have
learned. This includes an indication of whether the patient’s presenta
tion actually does or does not meet diagnostic criteria for ADHD and/
or any other co-occurring problems that seem important. We also try to
highlight the specific strengths of the patient that may have helped him
or her to cope with the ADHD impairments. We also acknowledge any
specific stressors in past and/or present that have complicated or im
peded the patient’s efforts to deal with ADHD. In doing this, we often
use the circles inside squares graphic organizer (Brown 2005b), which is
available on my Web site (www.DrThomasEBrown.com). We then in
vite questions from the patient and any family members. This leads to a
brief description of “where to from here” options for follow-up; these
may include treatment, further evaluation, or neither. We also provide
an opportunity for the patient and family to raise and get answers to any
additional questions or concerns they may have.
Education about ADHD should not be limited to the initial consulta
tion. We usually provide each new patient with a packet of written infor
mation to take home. The packet includes some fact sheets and articles
about ADHD and its treatment. We encourage patients to get back in
touch with us if they have additional questions or concerns after com
pleting the interview. Often patients will want to schedule a follow-up
appointment as we conclude the initial consultation.
Some patients come to their initial consultation after having tried
some medications for ADHD. If so, during the clinical interview we will
discuss with them what they see as the benefits and/or problems asso
ciated with medications they are currently taking or have taken in the
past. This discussion may lead to our making suggestions for them to
take back to their prescriber or an offer to be available to consult with
their prescriber if they wish. To facilitate this process, we provide the pa
tients with a packet of written materials about ADHD and their evalu
ation data to take to their prescriber for follow-up.
If the patient has ADHD and is not currently taking any prescribed
medication for ADHD and is interested in a trial of medication, we usu
ally offer to provide a brief note to be taken to the patient’s primary care
provider or referring clinician. That note briefly summarizes the evalu
ation findings and suggests that the patient be given a physical exami
nation to identify or rule out any medical problems that might impact
the choice of treatment plan, particularly the possible use of medication.
If the patient wishes, we also offer a recommendation for a specific
ADHD medication that seems likely to be most helpful. The patient can
give this suggestion to his or her referring clinician or to his or her pri
mary care provider along with our offer to collaborate with that clini
cian in developing and monitoring a treatment plan for the patient’s
ADHD if that is agreeable to the clinician and the patient.
Most of our patients diagnosed with ADHD choose to return to us to
collaborate in designing and monitoring their treatment for ADHD. For
some, this involves just a few additional visits, after which they are fol
lowed by other providers with the option to return to the clinic for fur
ther consultation if needed. Others engage in more intensive and
sustained treatment in our clinic for their ADHD and any related disor
ders that concern them.
Some other patients, for various reasons, do not want to engage in
any kind of treatment for their ADHD in response to their initial consul
tation. In such cases, we offer the patients written information and as
sure them that they are welcome to return at any time if they have
further questions or want to reopen discussion of possible treatment op
tions.
Guidance for Parents

If the patient is a child or adolescent, it is important for parents to have
access not only to scientifically accurate information about ADHD.
They also need, and usually ask for, guidance about how they can best
help their son or daughter with ADHD to function more effectively in
school, in peer interactions, and within the family.
Some of the issues parents most often ask about are listed below:
• Is medication for ADHD safe for our child, and if so, what medica
tion is likely to work best? What side effects may occur, and how can
you tell if the medication is working? What monitoring do we need
to do, and how often should we meet with the clinician?
It is important for the clinician to take sufficient time to address wor

ries of parents about whether the suggested medication may have
harmful effects. If such concerns are not adequately expressed and
addressed, parents’ fears may lead them to avoid giving the pre
scribed medication to their child or to discontinue use of the medica
tion precipitously because of unwarranted fears. It is also important

for parents to have information about how they can tell if the medi
cation is working effectively. For example, if a child is taking a med
ication in the morning that wears off soon after or perhaps even
before the end of the school day, parents may hear from teachers that
the medication is helpful to their child, yet they may see little change
or even increased difficulties after school because the medication has
worn off or is causing rebound symptoms. For this reason, it is often
helpful for the medication to be started on a weekend, when the par
ents have more opportunity to observe the child’s responses to the
medication at various times of day.
Another important fact to communicate prior to starting a new
medication is that it takes time to determine an effective medication
and dose for any specific individual. Parents and patients need to
know, as is described in Chapter 10 (“Practical Aspects of Medication
Treatments for ADHD”), that the optimal dose of a stimulant is not
directly correlated with the patient’s age, weight, or symptom sever
ity; it depends on the individual’s body sensitivity to that particular
medication. Titration is the search for the “sweet spot” between too
little medication and too much. They also need to know that some
times the medication initially chosen may not be effective or may
produce side effects that require not just a change of dose but also,
possibly, a change to another medication.
It is also helpful to schedule the child and at least one parent to re
turn for a follow-up visit with the clinician after the child has been
taking the medication for a couple of weeks. Parents also appreciate
being invited to e-mail or telephone the clinician if they have any
concerns about the medication’s effects that they want to discuss be
fore the return visit. If the medication prescribed is a nonstimulant or
another class of medication, such as an antidepressant, that requires
4–6 weeks before any benefits can be observed, it is important for
parents and the patient to have that information before beginning the
medication trial. Wilens and Hammerness (2016) have written a very
helpful book, Straight Talk About Psychiatric Medications for Kids, now
in its 4th edition, for parents who want understandable information
about various medications used for ADHD and related problems in
children.
• How can we resolve differences of opinion between us, his parents,
about the best ways to make decisions, not only about medication
but also about how to deal with our child’s behavior in ways that are
not too harsh and not too lenient?
Medication treatment for ADHD in children depends on the continu

ing and consistent support of parents and/or other caretakers to ob
tain, dispense, monitor, and refill the medication. The clinician
should explicitly inquire about whether there are significant differ
ences of opinion between parents about the use of medication for
their child's ADHD. If these are present, the clinician should try to
learn about the specific concerns felt by each and try to sort out a mu
tually agreeable resolution. Sometimes such differences are based on
one parent’s not being adequately informed about ADHD and the ba
sic facts about the medication. In other situations, there may be subtle
or overt conflicts between the parents that are based not on the facts
of ADHD and its treatment but on persisting disagreements about
other, perhaps more deep-seated, conflicts between them. When such
differences become apparent, these should be clarified and sorted out
by the clinician with the parents.
Parents also may differ on their attitudes about how to respond to
their son’s or daughter’s behavior in school or at home. As is de
scribed in Chapter 9 (“Emotional Dynamics in Individuals, Couples,
and Families Coping With ADHD”), if not recognized and construc
tively dealt with by the clinician, such parental conflicts can sabotage
the child’s treatment and exacerbate family stress. Some parents find
the following books helpful for understanding and managing ADHD
problems in their children:
• Barkley RA: Taking
Charge of ADHD: The Complete Authoritative
Guide for Parents, 3rd Edition. New York, Guilford, 2013
• Barkley RA, Benton CM: Your Defiant Child: 8 Steps to Better Behav
ior, 2nd Edition. New York, Guilford, 2013
• Barkley RA, Robin AL: Your Defiant Teen: 10 Steps to Resolve Conflict
and Rebuild Your Relationship, 2nd Edition. New York, Guilford,
2013
• Dawson P, Guare R: Smart but Scattered: The Revolutionary Executive
Skills Approach to Helping Kids Reach Their Potential. New York,
Guilford, 2013
• Nadeau KG, Littman EB, Quinn PO: Understanding Girls With
ADHD: How They Feel and Why They Do What They Do, 2nd Edition.
Washington, DC, Advantage Books, 2015
• Phelan TW: 1-2-3 Magic: Effective Discipline for Children 2–12, 3rd
Edition. Glen Ellyn, IL, ParentMagic, 2003
• How can we protect our child from becoming demoralized about
having ADHD? How can we set and maintain reasonable expecta
tions to encourage good effort in school and in carrying out respon
sibilities at home? We don’t want ADHD to become an excuse for

laziness or unacceptable behavior.
The best way to protect a child from becoming demoralized about
having ADHD is for the child’s parents to have a good understand
ing of what ADHD is and what it isn’t so they can help their child to
gradually develop an accurate and constructive attitude about
ADHD. It is not easy to maintain a reasonable balance between un
derstanding that the child with ADHD is experiencing some difficul
ties that, despite appearances to the contrary, are not willful and are
not under voluntary control, and at the same time supporting the
child and requiring that he or she make the best possible use of his or
her strengths and the supports available. These difficulties are dis
cussed in several of the case examples in Chapter 9.
• What should we tell the school? Should we be asking teachers to

make changes in how they deal with our son or daughter? If he or she
is labeled as having ADHD, will that lead to being embarrassed and
treated as “different” by teachers and peers?
Usually, though not always, a student being evaluated for ADHD has
been having significant difficulties in school. Frequently, the ADHD
evaluation has been, in large part, sparked by those difficulties.
Sometimes the problems are behavioral, sometimes they are aca
demic, and often they are both. For students in elementary or second
ary school, the evaluation usually involves seeking information from
teachers about the strengths and difficulties of the student in school
functioning. Once an evaluation has been completed, if the student
has been found to have ADHD, it is usually a good idea for the par
ents to discuss the diagnosis with the student’s primary teacher. It is
important for parents to be aware that increasing numbers of teach
ers are well informed about ADHD and can offer valuable help in
planning ways to help students with ADHD to improve their func
tioning in school. However, it is also important for parents to know
that although all experienced teachers have had experience in deal
ing with students with ADHD, many are not aware of current under
standings of ADHD, and some, lacking adequate training in this area,
hold negative attitudes about the diagnosis and are unaware of best
practices for dealing with those students.
After learning that their child has been diagnosed with ADHD,
parents should inquire of the teacher or principal about what the
school’s usual policies are for supporting and accommodating stu
dents with ADHD. Information about possible supports and accom
modations for ADHD in school can be found later in this chapter. The
main point here is that parents should find out about the policies and
attitudes about ADHD held by teachers and administrators in their
child’s school and then seek to collaborate with school staff to plan
for minimizing negative effects and optimizing their child’s learning
and behavior in light of the ADHD diagnosis. It is also important for
parents to keep in mind that there are necessary limits to how much
any given teacher and school can or should accommodate to the
needs and desires of any one student and his family. If parents find
that some of their child’s teachers do not have up-to-date information
about ADHD, they may want to print and provide copies of the arti
cle “ADHD: From Stereotype to Science,” a piece written by the au
thor of this book that was published in Educational Leadership (Brown
2016), a national magazine for teachers. A copy can be found at my
Web site (www.DrThomasEBrown.com).
• One of us parents probably has ADHD and has never been treated for
it. Should we get evaluation and treatment for this? Would that help
our child?
As mentioned in Chapter 1 (“Basic Facts and the Central Mystery of

ADHD”), ADHD is highly heritable, and about 25% of persons diag
nosed with ADHD have a parent with ADHD. In many cases, the
parents are not aware of their ADHD until they bring their child to a
clinic for evaluation and learn about the symptoms and impact of this
disorder. At that point, many parents are quick to recognize that one
or both of them endured similar difficulties at a comparable age. In
some cases, the parent has outgrown those ADHD symptoms and is
functioning well, but in many cases, that parent is still struggling in
adult life with impairments of ADHD.
If the parent currently has significant problems with ADHD
symptoms, it is usually a good idea for that parent to seek evaluation
to determine whether there is sufficient current impairment to war
rant an ADHD diagnosis and to begin appropriate treatment. There
is some evidence that parents with current and untreated ADHD im
pairments are less effective in supporting the treatment and develop
ment of their child with ADHD. If the parent had ADHD earlier but
has now outgrown or adequately compensated for the ADHD
related impairments, that parent should be able to provide especially
empathic support for his or her child with ADHD, so long as he or
she realizes that the child’s experience of ADHD may be quite differ
ent from the parent’s own earlier experiences.
• How can we provide the help that our child with ADHD needs at
home without being unfair to our other sons and daughters?
Often a child with ADHD needs a disproportionate share of attention

and support from his or her parents, particularly during the earlier
years. This can create understandable frustrations and conflicts
within or between the parents and within the whole family system.
Siblings are likely to develop subtle or very explicit jealousy and re
sentments over why their brother or sister with ADHD seems to be
getting more parental time and attention, more privileges, or more le
nient treatment than other children in the family. Even if parents are
very careful to be consistent in rewards and punishments and to bal
ance their time and privileges for each of their children, there are of
ten subtle but difficult burdens experienced by siblings of children
who have significant impairments from ADHD and/or other disor
ders. Jeanne Safer (2003) has written sensitively about the burdens of
being “the normal one” in a family with a difficult sibling.
• Does our child need some kind of counseling or therapy to deal with
his or her ADHD and/or related problems? If so, where can we find
the right help?
When parents discover that their child has a significantly impairing dis
order, especially if they have overlooked or misinterpreted that prob
lem for some time, they are likely to want to do everything possible to
address that problem immediately in multiple ways. That may be a
mistake. First, it is usually not easy to find adequate professional help
for ADHD, particularly if it is complicated by anxiety, depression, sub
stance abuse, a specific learning disorder, or other co-occurring prob
lems. Second, suddenly pushing a child (or anyone else) to see and be
evaluated and treated by a variety of different clinicians for any prob
lem is likely to generate a “something very serious is wrong with me”
feeling. Deciding on a treatment approach usually works best if there is
one clinician who serves as case manager to help parents identify what
interventions are likely to be helpful to their child and to figure out
what is actually necessary and available. For some persons with
ADHD, particularly adolescents and adults, it may be very helpful to
have some conversations or psychotherapy with a knowledgeable and
empathic clinician about how their ADHD has impacted them and
what practical steps they might take to improve some of their difficul
ties. For others, particularly younger children, it may be best for the
consultations to be provided primarily to the parents so they can be an
ongoing source of support as their child is learning to deal with ADHD.
• Is our child’s ADHD likely to get better or worse as time goes on?
What does this mean for his or her future education, relationships,
and career?
It is certainly very understandable that parents want to know how

ADHD is likely to have an impact on their son or daughter, but there
is no crystal ball to provide a credible answer to that seemingly sim
ple question. There are too many complex factors that influence out
come. In Chapter 6 (“How ADHD Develops, Sometimes Gets Worse,
and Sometimes Improves”), I describe how ADHD sometimes im
proves and sometimes gets worse over time. Processes of brain de
velopment that may have been delayed may then catch up a little or
a lot. The nature of the home, school, and community environment
can make a significant difference in how much the child with ADHD
feels safe, accepted, and supported or harshly criticized, bullied, or
rejected.
Having or lacking supportive parents and other relatives, teach
ers, friends, and mentors can make a huge difference. A child with
striking personality characteristics and social skills or one who has
exceptional cognitive, athletic, artistic, or musical talents may com
pensate very well for ADHD impairments. Some children with
ADHD are quite resilient and have extraordinary persistence in mak
ing strong efforts to overcome challenges that they face. Some are for
tunate and enjoy good health, whereas others struggle with multiple
health problems, often without adequate resources to obtain effective
treatment. Life is not always fair.
However, despite these multiple factors that may influence devel
opment of an individual with ADHD for worse or for better, it is im
portant for parents to know that there are many persons with ADHD
who eventually do very well in their education and who are quite
successful in completing their schooling and developing a successful
career and satisfying relationships with friends, family, a partner, and
offspring.
Collaboration With Elementary

and Secondary Schools
When a child in preschool, elementary school, or secondary school is be
ing evaluated for possible ADHD, it is important to obtain information
about how that student is functioning academically and socially in
school. Parents can supply useful information about what they notice
about their child’s attitudes, comments, and behavior with respect to

going to school, relating to teachers, interacting with classmates, and
doing homework. They can also share copies of report cards, notes sent
home by teachers, reports of standardized testing, and other records.
Parents will also have considerable anecdotal information about their
child’s school experience that is not available to the child’s teachers.
Teachers can also provide information that is not directly available to
parents. Especially in lower grades, where the student is with just one
teacher for most of the day, the teacher has a wealth of information about
how each child interacts with him or her and how the student responds
to various types of assignments—what learning comes easily and what
is more challenging, how the student listens and follows directions, and
how much the student needs to be reminded to persist in working on an
assigned task. The teacher also can report on how the child interacts with
classmates during organized group activities, while working with part
ners or small groups, and in unstructured free time or play situations.
Most important, the teacher is able to observe the student’s behavior rel
ative to that of a group of other children of similar age.
Most parents have only very limited opportunities to observe their
son or daughter with a diverse group of children of similar age. Teach
ers, especially those who have been teaching a particular grade level for
more than just a couple of years, have had sustained opportunity to wit
ness a large sample of students of a given age in a wide variety of situ
ations. Their perspective can be quite helpful, especially when parents
lack experience with many children of their child’s present age. Teach
ers are generally more aware of the wide range of normal development
in the age groups with which they work.
Teachers of students in secondary school can provide helpful infor
mation about their students, but their perspective is generally more lim
ited than that of elementary school teachers because most secondary
school teachers have many more students each day and much less op
portunity to observe those students in diverse activities. A typical high
school teacher has five classes each day, each of which may include 25 or
more students. He or she may become well acquainted with some of the
students who are more active class participants or who seek conversa
tion after class, but high school teachers do not have much opportunity
to interact personally and really get to know many of the students who
are in and out of their classroom each day.
Teachers also vary in their ability and willingness to observe and de
scribe their students. Some teachers are extremely perceptive in dealing
with their students. They notice fluctuations in their students’ moods
and energy levels and their degrees of interest and motivation for vari
ous tasks and types of learning. They watch how students interact with
one another and notice subtle changes in the dynamics of friendships
and alliances and conflicts between subgroups. Some teachers function
as trusted, empathic advisors for particular students, whereas they may
be seen by other students as harsh critics or overbearing managers or
menacing adversaries.
There are also differences among teachers in their willingness to share
information with inquiring parents. In some schools, there is an adminis
trative climate that urges teachers to be very cautious in telling parents any
thing about their son’s or daughter’s performance that might be taken by
the parents as overly harsh or critical. Those teachers may be instructed to
limit their reports to parents to just factual recitation of grades on assign
ments or very limited description of behavior, without any elaboration as to
what the teacher has noticed about the student’s attitude, social interac
tions, or more subtle aspects of his or her functioning in school.
Most school districts have a policy that forbids teachers from sug
gesting that a student may have ADHD, a learning disability, or any
other specific problem. Such policies have been put in place because
some teachers in the past have told parents that their child has ADHD
and insisted that the child be prescribed medication, seriously overstep
ping the boundaries of their training and competence. Yet, in some
schools, that caution against suggesting a diagnosis has been inter
preted as a requirement to refrain from making even such statements as
“Your child seems to have much more difficulty in focusing than most
others of similar age. You might want to consider asking your pediatri
cian about that.”
The usual way for most clinicians to solicit information about the
school functioning of a student being evaluated for ADHD or related
problems is to obtain copies of recent report cards from the parents and
to provide parents with rating scales they can take to teachers to request
specific information relevant to the evaluation. Many pediatricians use
the Vanderbilt ADHD Diagnostic Parent Rating Scale (National Insti
tute for Children’s Health Quality and American Academy of Pediatrics
2011) for this purpose. Schools and specialist clinicians more often use
other scales for teachers such as the Behavior Assessment System for
Children—Third Edition (BASC-3; Reynolds and Kamphaus 2015), Be
havior Rating Inventory of Executive Function (Gioia et al. 2000), Brown
Attention Deficit Disorder Scales (Brown 2001), Comprehensive Execu
tive Function Inventory (Naglieri and Goldstein 2013), or Conners
ADHD Rating Scales—3 (Conners 2008a); these rating scales are normed
and elicit more comprehensive information relevant to current under
standing of ADHD.
If information from teachers or parents suggests that the student be

ing evaluated might have a specific learning disorder involving impair
ment in reading, written expression, or mathematics, there is reason to
have individualized psychoeducational testing done to inform the di
agnosis and treatment planning. Sometimes this testing can be done by
the school and shared with the evaluating clinician. If not, it may be pos
sible to arrange private testing, which can then be shared with the
school.
In the United States, there are two levels of federal laws that provide
for students with disabilities who may need accommodations and/or
supports that are not provided for most students:
• Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112) established

requirements for accommodations and support for individuals with
a disability, including ADHD or a specific learning disability, when
such accommodations are needed for them to get an appropriate ed
ucation. A Section 504 plan, or a 504 plan as it is also referred to, is
usually utilized when the student with a disability such as ADHD
needs accommodations and/or supports that can be provided within
mainstream classrooms and does not need special education ser
vices.
• The Individuals with Disabilities Education Improvement Act of
2004 (IDEA) (P.L. 108-446) and the IDEA amendments of 2006 (P.L. 94
142) are the most recent versions of laws first passed by Congress in
1975. This law and amendments provide detailed regulations to en
sure that students with disabilities who need special education and
related services are provided a free and appropriate education.
When a parent requests services for their child with a disability such
as ADHD or a specific learning disability, the school is required to con
vene within 45 days a meeting that usually involves the parents, one or
more of the student’s current teachers, the school psychologist, a special
education teacher, the school nurse, and the principal or another desig
nated administrator of that school. At that meeting, the parent’s concerns
are heard and the school staff members present updated information on
the student’s educational history, current functioning, and other relevant
background information. At the meeting, it is determined what further
action may be needed; this may include arranging for psychoeducational
testing or other specialist assessments.
Among the actions might be development of a 504 plan. This plan
provides supports and accommodations for a student with an identified
disability (e.g., ADHD, learning disability) that can be implemented
within the mainstream classroom without need for special education

services. The following are among the possible accommodations:
• Extended time for completing timed tests or examinations (usually

1.5 of the usual time)
• Reduction in the amount of written work required or extended time
for completion
• Daily teacher verification that the student has correctly recorded as
signments
• Alternative seating of the student in the classroom (e.g., closer to
teacher)
• Use of a calculator for math or computer for written work
• More frequent reports from school to home, possibly including daily
report forms
• Behavioral interventions such as a point system to reinforce good be
havior
Accommodations and supports provided in a 504 plan are based on

agreement between the parents and the school for the current school
year. Usually, the 504 plan is reviewed, and revised if needed, at least
once each year.
Extended time for taking tests and exams is the most frequently re
quested accommodation among students with ADHD and/or other
learning problems. Although some students with ADHD tend to rush
too quickly as they take tests, as though the goal is to finish as quickly as
possible, many, though not all, students with ADHD need to work
slowly and have great difficulty in demonstrating what they have
learned when they are tested under tight time limits. Often they need to
reread passages of text repeatedly to fully grasp what is being said and
what the exam question is asking. (For information on how extended
time can improve reading comprehension on tests for students with
ADHD, see Brown et al. 2011b, which is also available at my Web site,
www.DrThomasEBrown.com/.) On math tests, persons with ADHD often
need more than the usual time to go back and check their calculations so
they can correct careless errors or possible misunderstanding of the prob
lem due to their not paying enough attention to details. Likewise, many
with ADHD need extended time for tests that require written expression.
They may have good ideas about what to write and what information to
provide, but many have difficulty in organizing their information and in
translating their thoughts into sentences and paragraphs.
When extra time for taking exams is needed by a student because of
his or her ADHD or some related disability, a 504 plan can authorize this
extra time, ordinarily 1.5 of the usual time, for tests and exams given in
the local school system, including state-mandated exams. However, a
504 plan or individualized education plan (IEP) does not, in itself, pro
vide accommodations for students taking national exams used for col
lege applications such as the SAT or the American College Testing
(ACT) exam.
Accommodations such as extended time for the SAT and/or ACT are
not obtained simply by having a 504 plan or an IEP. These national exams
require a detailed report documenting the nature of the student’s disabil
ity with evidence from school reports, standardized testing (usually in
cluding a full IQ test), academic achievement testing, and a clinical
evaluation done by a qualified professional such as a clinical psychologist
or neuropsychologist who is familiar with requirements for such accom
modations. This report has to be submitted with a specific application for
accommodations, in addition to the usual application for taking the
exam.
An application for accommodations must be submitted to the SAT
and/or ACT office at least 6 weeks prior to the date the student hopes to
take the exam. Representatives of the SAT or ACT then review the re
port to see if it meets requirements that are published on their Web site.
If so, extended time is granted. If not, the reviewer will deny the request
and notify the student as to what additional information would be re
quired for accommodations to be granted. If a request for accommoda
tions is denied, the student may get the decision reversed if additional
assessment data or other information required by the ACT or SAT re
viewers is provided in an appeal submission.
For students with identified disabilities whose needs cannot be met
adequately with just a 504 plan, the school is required by federal law to
convene a planning and placement team (PPT) meeting, where it will be
initially determined what additional assessments are needed for ade
quate planning. Once those data are obtained, the school develops an IEP,
which stipulates the nature of the student’s disability and provides guid
ance for needed services, such as remedial instruction, speech/language
or occupational therapy services, and/or accommodations such as ex
tended time for tests. The IEP identifies specific objectives and goals for
intervention, identifies professionals to provide needed interventions,
and specifies the frequency and amount of time for each intervention to
be provided.
Usually, those accommodations and interventions can be provided
by special education teachers or other specialists located within the
school; if not, visits from additional specialists needed may be arranged.
It is required by law that these plans be reviewed at least annually and
that appropriate retesting be done in preparation for the triennial re

view after the program has been in place for 3 years. The school is re
quired to provide to parents a copy of the written IEP and detailed
written minutes of each PPT meeting. If parents and local school staff
are not able to reach agreement regarding the IEP, the parents have the
option to request an appeal meeting with the central administration of
the school system.
In some cases, a child’s needs cannot be met adequately with the re
sources of the local school system. In that event, the PPT may determine
that placement in a more specialized program outside the local school
system is necessary to provide that student with an adequate education.
In such cases, the school system is obligated to pay whatever costs are re
quired for that placement and to monitor the student’s progress in that
placement. It should be noted that the school’s obligation under law is to
provide the student a free and appropriate education, not an optimal or
ideal education. Sometimes parents who are anxious to provide the best
possible resources for their child forget that the school system has lim
ited resources with which to provide an appropriate education for all the
students in that school system.
If parents have placed their son or daughter in an independent pri
vate or religious school, unless that school receives federal funds, it is
not under any legal obligation to follow federal laws regarding accom
modations and supports under Section 504 of the Rehabilitation Act of
1973 (P.L. 93-112) or the Individuals with Disabilities Education Im
provement Act of 2004. Sometimes such schools cooperate in providing
such services and accommodations, but they are not legally required to
do so. Parents may request that the school district in which the indepen
dent school is located provide needed assessment and services if their
child has a documented disability.
Parents who want to seek help from the school that their child is at
tending may want to get additional information or resources for them
selves or to share with teachers or school administrators. The Web site
www.Understood.org has a lot of readily understandable information
in English and in Spanish about how parents can help their children
who suffer from attention and learning issues. Russell Barkley (2016)
has published Managing ADHD in School: The Best Evidence-Based Meth
ods for Teachers, which offers many practical suggestions about how
teachers can help students deal with ADHD-related executive function
problems in the classroom. A good guidebook for elementary school
teachers is Sandra Rief’s (2005) How to Reach and Teach Children With
ADD/ADHD: Practical Techniques, Strategies, and Interventions. Chris A.
Zeigler Dendy (in press) has authored an excellent and practical book
for parents and teachers of secondary school students: Teenagers With

ADD, ADHD & Executive Function Deficits: A Guide for Parents and Pro
fessionals.
Accommodations in College
and Postgraduate Settings
For students with ADHD or related difficulties who enroll in postsec
ondary schooling, the college or university has no obligation to provide
accommodations or support services unless the student notifies the
school and provides appropriate documentation. Many schools will ac
cept a high school 504 plan or IEP, or the reports used to obtain accom
modations on the SAT or ACT, as sufficient evidence of the student’s
need for accommodations. However, some students who demonstrated
no need for accommodations in high school find they do need accom
modations to deal with the more challenging requirements of college.
Those accommodations may include extended time for exams, a mini
mally distracting setting for taking tests, or a peer note-taker whose
notes from a lecture can help to compensate for the student’s difficulty
in rapidly taking notes during class. If the student has had no accom
modations in elementary or high school, usually the college will require
a report similar to what is usually required for the SAT or ACT.
Some college students find that they need accommodations for
ADHD in the latter years of their undergraduate studies even though
they did not apply for or feel a need for any accommodations previ
ously. This may be due to not having recognized and been diagnosed
with ADHD earlier, or they may feel need for accommodations because
of increased demands for executive functions in meeting requirements
for more advanced courses. Some other university students with
ADHD may discover that they need accommodations for examinations
such as the GMAT, LSAT, or MCAT to gain admission to graduate-level
programs. Graduate students with ADHD may need accommodations
for taking exams such as the United States Medical Licensing Examina
tion, law boards, or other exams required for entrance into practice of
their profession.
For those who are applying for test-taking accommodations for the
first time relatively late in their education, it is important to ensure that
the person administering the required standardized tests also includes
in the report an adequate explanation of why accommodations are be
ing sought now when they were not sought in earlier years of schooling.
Some of the organizations offering such accommodations are exces
sively stringent in enforcing their requirements for accommodations.

For example, in 2015 the board that administers the LSAT was presented
by a federal court with an order to modify their stringent policies that
blocked many applicants from getting needed accommodations for that
exam.
Most colleges and universities now provide learning support ser
vices such as a writing center, where any student can seek assistance for
preparing term papers or other writing assignments, or academic
coaching to help students in planning and organizing their work. How
ever, unlike support services in elementary and secondary schools,
where students are required to show up for designated services and are
confronted and may be disciplined if they do not show up when sched
uled, support services in college do not require students to show up for
assistance and do not seek out a student who has signed up for support
services and then not kept appointments.
Most colleges and universities also have mental health or counseling
services where students struggling with academic demands, social dif
ficulties, anxiety or depression, substance use, sleep problems, or other
impairments can obtain assistance from a counselor. However, these
services usually require the student to take the initiative to seek an ap
pointment and to follow up. Moreover, many of these services are quite
limited in staff resources and need to limit the number of sessions for
any given student unless there is a very serious problem.
The transition from high school to college involves major changes
for students, especially during their first year. Usually, students spend
many years in relatively stable school placements where they are famil
iar with expectations and know their status and routines in classroom
and community while continuing to live with their own family. For
many, going off to college means giving up their familiar community
settings and having to adjust to new friends and a new community. In
their new surroundings, they cannot initially know what to expect, and
they may struggle with uncertainties about how much they will like and
be liked by other students and about how they will fare academically in
their new setting and new level of study. Many also worry quite a bit
about how their siblings and family will get along without them and
how they will be able to cope without the daily support and familiar
routines to which they have become accustomed. A Bird’s-Eye View of
Life With ADHD and EFD...Ten Years Later: Advice From Young Survivors,
3rd Edition, by Chris A. Zeigler Dendy and Alex Zeigler (2010); AD/HD
and the College Student: The Everything Guide to Your Most Urgent Ques
tions by Patricia Quinn (2012); and Smart but Stuck: Emotions in Teens and
Adults With ADHD by Thomas E. Brown (2014) are books many college
students and some parents have found helpful. Detailed legal informa
tion pertaining to higher education is provided in Peter S. Latham and
Patricia H. Latham’s (2007) book, Learning Disabilities/ADHD and the
Law in Higher Education and Employment.
Accommodations and Legal

Protections for Those With ADHD
in Employment Settings
Some adults with ADHD need accommodations in their work setting to
help compensate for their impairments of executive function. The Rehabil
itation Act of 1973 (P.L. 93-112), Section 504, and the Americans with Dis
abilities Act of 1990 prohibit discrimination in employment by private
employers, state and local governments, employment agencies, and labor
management committees. Under provisions of these laws, individuals with
ADHD or learning disabilities that significantly impair them, relative to the
average person, in important life activities are to be protected from discrim
ination in job recruitment, hiring, job assignments, pay, layoff, firing, train
ing, promotions, benefits, and leave. Information about when and how
employees with ADHD should consider seeking accommodations under
provisions of the Americans with Disabilities Act is provided in Kathleen
Nadeau’s (2016) The ADHD Guide to Career Success: Harness Your
Strengths, Manage Your Challenges, whereas more detailed information
about laws related to employees with learning disabilities or ADHD is
available in the book by Latham and Latham (2007) cited earlier.
Supportive Psychotherapy
for Young, Middle-Aged,
and Older Adults
After receiving a diagnosis of ADHD, many young and older adults
have three concurrent feelings. One important feeling is relief that there
is a name and a reason for many of the problems they have struggled
with and felt ashamed of for a long time. Another significant feeling is
hope that available treatments will be helpful in alleviating many of
those problems. A third common feeling is anger and resentment that
these problems were not recognized and treated long ago. They wonder
how different—how much better—their lives might have been if they
had been diagnosed and treated much earlier.
For some persons, it is important to talk with the clinician about

these feelings and others that arise in response to receiving an ADHD
diagnosis. For some, there is an excitement and optimism and new hope
for changing their current life situation and their educational, employ
ment, social, and family’s future. Others need to discuss and grieve a bit
over what might have been had the diagnosis and treatment come ear
lier. One of my patients expressed this by repeating the line spoken by
Marlon Brando in the movie On the Waterfront: “I could have been a con
tender!”
Other patients become overly excited and impatient, wanting to get
started immediately with medication treatment from which they are ex
pecting dramatic, life-changing benefits. For these patients, it is impor
tant that the clinician help them understand that the treatments are not
magical, that they do not fix all of one’s problems, and that the search for
an effective medication may not be quick and immediately successful.
Sometimes the process is frustrating and involves trying various doses
or encountering unwanted side effects or inconsistent results. It is im
portant that the clinician help the patient to be realistic about expecta
tions and to recognize that we clinicians cannot promise results that will
fully match the patient’s longing and needs.
Another area for which adults diagnosed with ADHD often need
supportive psychotherapy is dealing with co-occurring disorders. As
described in Chapter 7 (“How and Why Other Disorders Often Co-occur
With ADHD”), most adults (and many children) diagnosed with ADHD
also have one or more other learning, emotional, or behavioral disorders
at some point in their lives. Some have struggled significantly with sleep
and awakening, depression, anxiety, a learning disorder, obsessive
compulsive disorder, autism, substance use disorders, or other prob
lems for which they may or may not have been diagnosed and treated
prior to their evaluation for ADHD.
After receiving a diagnosis of ADHD, they may struggle to figure
out how much of those earlier struggles might have been an aspect of
their previously undiagnosed ADHD and how much those difficulties
were or are still a significant problem for them in addition to their
ADHD. Such questions are important, but often they require further
evaluation, which may have an impact on the person’s treatment for
ADHD. For example, some have struggled for many years with feeling
excessively anxious or suffer from mood problems. They may have been
and may currently be taking medications for those previously diag
nosed disorders. Medication started for their ADHD may exacerbate
those previous problems or may help to alleviate them. The clinician
should explicitly discuss with the patient at the time of initial evaluation
any co-occurring problems that are reported or noticed. That discussion

should include consideration of how treatment for ADHD might com
plicate or be complicated by other disorders present and/or any current
treatments for any other disorders. Moreover, the clinician should be
alert to the possibility that some co-occurring problems, which the pa
tient did not recognize or did not feel ready to report, may emerge and
need to be dealt with in subsequent sessions.
It is not only co-occurring psychological/psychiatric problems that
may complicate a patient’s functioning and treatment. Medical prob
lems also need to be considered. Does this person have a history of or
current difficulties with blood pressure, thyroid, growth delay, mi
graines, diabetes, heart irregularities, obstructive sleep apnea, allergies,
or other medical problems that may complicate his or her ADHD or
where medications used for treatment of the ADHD may cause difficul
ties? Before medication treatment for ADHD is initiated, the patient
should have a consultation with his or her primary care provider and
get a physical examination to determine whether there are any health
problems or any medications currently being taken that would compli
cate or possibly be a contraindication to receiving medication treatment
for ADHD.
One additional concern with which an adult recently diagnosed with
ADHD may want some help is dealing with the reactions of family, em
ployers, friends, or others to this new diagnosis. Some adult patients
meet with skepticism from a parent, spouse, or dating partner or among
friends when they disclose that they have been diagnosed with ADHD.
Others in the patient’s life may not believe that ADHD is a legitimate
diagnosis, may be convinced that the patient could fix all his or her dif
ficulties by simply trying harder, or may be worried that taking medica
tions for ADHD is likely to cause adverse effects or addiction. Many
patients are quite comfortable in addressing such concerns, but some
worry about how they can convince those persons important to them
that their ADHD diagnosis is reasonable and that the treatment being
undertaken is safe and likely to be helpful. It is important also to recog
nize that some patients project onto others negative aspects of their own
worries or ambivalence about the diagnosis and/or treatment. It may be
the patient who needs additional information and reassurance. A well
informed clinician can be quite helpful in addressing such difficulties if
time is allocated for such conversation.
Adults who want more information about ADHD may also benefit
from consulting the Web site of the National Resource Center on ADHD
(http://www.chadd.org/NRC.aspx) operated by Children and Adults
with Attention-Deficit/Hyperactivity Disorder (CHADD) with support
from the U.S. Centers for Disease Control and Prevention. In addition to
its Web site, the center offers a free newsletter about ADHD and a tele
phone helpline to answer questions with science-based information
about the disorder. Adults may also find useful information from look
ing at Attention or ADDitude, two magazines that often provide helpful,
updated information for and about persons with ADHD. Books that
may prove useful include the following:
• Brown TE: Attention Deficit Disorder: The Unfocused Mind in Children

and Adults. New Haven, CT, Yale University Press, 2005
• Brown TE: A New Understanding of ADHD in Children and Adults: Ex
ecutive Function Impairments. New York, Routledge, 2013
• Brown TE: Smart but Stuck: Emotions in Teens and Adults With ADHD.
New York, Jossey-Bass, 2014
• Hallowell EM, Ratey JJ: Driven to Distraction: Recognizing and Coping With
Attention-Deficit Disorder. New York, Random House Digital, 2011
• Hinshaw SP, Ellison K: ADHD: What Everyone Needs to Know. New
York, Oxford University Press, 2016
• Solden S: Women With Attention Deficit Disorder: Embrace Your Differ
ences and Transform Your Life. Nevada City, CA, Underwood Books,
2012
• Tuckman A: More Attention, Less Deficit: Success Strategies for Adults
With ADHD. Plantation, FL, Specialty Press, 2009
Cognitive-Behavioral Therapy
Although medication is usually the most effective treatment for ADHD,
many individuals continue to struggle with executive function impair
ments in daily life that are not adequately alleviated by medication
alone. For many of these individuals, especially adolescents and adults,
cognitive-behavioral therapy (CBT) can be very effective, especially
when used in conjunction with adequately fine-tuned medication treat
ment and when provided by a clinician who has learned to adapt tradi
tional cognitive-behavioral methods to treatment for ADHD.
CBT is quite different from many traditional forms of psychotherapy.
It focuses on specific assumptions or thoughts that lead to and reinforce
problematic behaviors, but it is concerned with not only those assump
tions and thoughts but also the resulting problematic behaviors. Its focus
is cognitive and behavioral—how one thinks about and interprets events
of daily life—and how those often-unrecognized thoughts and interpre
tations can interfere with managing many aspects of daily life.
For example, a cognitive-behavioral approach might challenge a

person who has given up on trying to find a suitable dating partner (“I
have ADHD, and there is just no one I would ever want to date who
would be available for me”). That therapist might help the discouraged
patient to recognize that ADHD does not need to be an impediment to
forming relationships and that there may be some desirable dating part
ners out there, to think about specific actions that might increase the
chances of meeting one, and then to actually try to engage in those ac
tions. Patient and therapist would then follow up to collaborate about
how those actions could be made more effective.
A similar approach might be taken to other emotionally loaded as
sumptions common among persons with ADHD, such as the following:
“I can never get a term paper or a report in on time.” “I’m just no good
at managing money; I always spend too much and then don’t have
enough money to pay my bills.”
The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
and Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychoso
cial and Medical Approach, 2nd Edition, both written by J. Russell Ramsay
and Anthony Rostain (Ramsay and Rostain 2015a, 2015b), provide a very
practical description with many examples of how cognitive-behavioral
methods can be adapted for adults with ADHD and integrated into a
comprehensive treatment program with medication. Another useful
book is Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive
Dysfunction by Mary Solanto (2013). It describes a systematic program
that can be used in group settings or individual sessions to help adults
with ADHD improve executive functions such as organization and time
management.
Couple Therapy for Adults

Often persons with ADHD have difficulty in relationships with dating
partners or spouses. The partner often becomes frustrated with the per
son’s being chronically inattentive, distracted during conversations, im
pulsive in making decisions, unreliable in showing up on time or in
carrying out responsibilities he or she agreed to take on, or volatile in ex
pressing emotion. Such difficulties can lead to chronic escalation of frus
trations and repeated arguments that resolve nothing and leave both
parties feeling hurt, resentful, and misunderstood in ways that can un
dermine and, in some cases, totally disrupt the relationship.
Many of the conflicts experienced in relationships involving one or
both partners having ADHD are not unique to relationships involving
ADHD. Developing a relationship in which two people, each with a dif

ferent personality and a different history of life experiences, are learning
to know and become intimate with each other, especially if one or both
want to maintain long-term commitment with the other, is a complex
and dynamic process that inevitably involves conflict. Differences arise
over how to spend time or money, when to go to bed, how to deal with
relatives, and countless decisions ranging from trivial matters to major
life decisions. Yet when one or both persons in the relationship have
ADHD, the executive function impairments of ADHD are likely to fur
ther complicate an already complicated process.
Providing therapy for any couple is a complicated task; it is even
more complicated in couples when one or both have ADHD. The most
basic task is to create and maintain an environment in which both par
ties can feel safe and protected from the intense embarrassment and
hurt that can result when the vulnerabilities of one partner are exposed
and verbally attacked by the one person who has intimate knowledge of
a partner. The impulsivity, emotional volatility, and inattention to de
tails of a current situation that sometimes characterize those with
ADHD can substantially escalate the challenge of doing conjoint ther
apy with a couple when one or both have ADHD.
Yet, as difficult as conjoint therapy sessions with a couple can be,
such sessions are often the most effective way to address conflicts be
tween intimate partners. Even when sincerely trying to tell the whole
truth, any individual is likely to present an account of interactions with
his or her partner that is biased, if not grossly distorted, by his or her
own assumptions and limited recall. There is always some other side to
the story. Often a conjoint therapy session can provide the only place
where a therapist has the opportunity to understand each partner’s re
call of, reactions to, and assumptions about the couple’s shared experi
ences. And the conjoint session may also be the only place where each
partner can hear and actually listen to the concerns of the other with
some empathy. Resources to guide a therapist in this process have been
provided by Gina Pera and Arthur Robin (2016) in their Adult ADHD-
Focused Couple Therapy: Clinical Interventions. Books that may be helpful
to partners trying to think about the role of ADHD in their intimate re
lationships include Melissa Orlov’s (2010) The ADD Effect on Marriage:
Understand and Rebuild Your Relationship in Six Steps; Gina Pera’s (2008) Is
It You, Me, or Adult A.D.D.? Stopping the Roller Coaster When Someone You
Love Has Attention Deficit Disorder; and Married to Distraction: Restoring
Intimacy and Strengthening Your Marriage in an Age of Interruption by Ed
ward Hallowell, Sue George Hallowell, and Melissa Orlov (Hallowell et
al. 2010).
Coaching for ADHD

Another resource for individuals with ADHD who are struggling to
make changes in their daily life is individual coaching. An ADHD coach is
a person who has been trained to understand ADHD and the variety of
ways in which it affects individuals and who has learned various strat
egies and techniques to help and monitor those with ADHD who are en
gaged in the often frustrating and bewildering task of trying to change
unproductive patterns of ADHD-related attitudes and behaviors.
For many years, there was no certification process for ADHD
coaches; anyone could announce himself or herself as an ADHD coach
and charge fees for providing services to persons who wanted to hire
him or her. Typically, ADHD coaches are not licensed medical or mental
health professionals. Often they are adults who themselves have ADHD
and have sought training so they can provide advice and emotional sup
port, face-to-face and/or by phone, to others who might benefit from
their experienced perspective. They usually focus on helping their cli
ents with strengthening organizational skills, prioritizing tasks, reduc
ing procrastination, improving interpersonal skills, self-monitoring,
and improving self-esteem.
A number of organizations now offer training opportunities and
various levels of certification for ADHD coaches. In the United States,
these include the ADD Coach Academy (http://addca.com/), JST
Coaching & Training (www.jstcoaching.com/), Coach Approach for Or
ganizers (http://coachapproachfororganizers.com), and FastTrack
Coach Academy (http://fasttrackcoachacademy.com). The Edge Foun
dation (https://edgefoundation.org) trains and provides coaches to
work on-site with middle school, high school, and college students who
need support for improving their executive functions; this national
foundation offers services for fees and scholarships for students who
need coaching support but cannot afford to pay for those services.
Alternative Treatments for ADHD

In addition to the nonmedication treatments for ADHD described ear
lier in this chapter, there are a number of other nonmedication alterna
tive treatments, many of which are advertised on the Internet and in
various publications. Often these ads include enthusiastic testimonials
from people who have used the method being advertised. Sometimes
advertising includes claims that these methods have been “developed
by neuroscientists” or “demonstrated to improve memory or other
symptoms of ADHD.”
A group of 21 respected European scientists who specialize in ADHD

research conducted a systematic review and meta-analysis of published
research studies on dietary and psychological treatments for ADHD
(Sonuga-Barke et al. 2013). Their study included restricted elimination
diets, artificial food color exclusions, free fatty acid supplementation,
cognitive training, neurofeedback, and behavioral interventions. Only
studies that included a control group for comparison and did not in
clude using medication for ADHD during the trial were considered. A
total of 2,904 published reports were evaluated, but only 129 articles ad
equately met the scientific standards for inclusion in the study.
The review showed that many of the included studies found positive
results when effectiveness was rated by persons who had been actively
involved in providing the treatment and knew whether individuals in
the study had or had not been receiving the treatment. Results were
much less positive when effectiveness of the intervention was evaluated
by persons who were blind to who had received the treatment and who
had not. For example, if parents had been involved in having their child
follow a diet that eliminated food coloring or required that the child do
a lengthy series of training sessions on a computer program over many
weeks, ratings provided by those parents tended to be quite positive.
But when the persons rating effectiveness of the intervention were
teachers or research technicians who did not know which participants
had received the intervention and which had not, the results were much
less positive and generally were not statistically significant.
In short, this extensive study found that unbiased reporters who had
no stake in the evaluation did not report significant benefits from these
interventions. Parents or clinicians who had a stake in the outcome, and
who had put their time, efforts, and/or money into providing the treat
ment, tended to report much more positive outcomes. Such biased re
ports do not meet scientific criteria for evidence of effectiveness. A more
recent study did a meta-analysis of cognitive training for ADHD and
also found very limited effectiveness demonstrated in blinded studies
(Cortese et al. 2015).
Four respected American psychologists (Rapport et al. 2013) pub
lished a meta-analytic study that focused specifically on commercially
marketed computer training programs designed to train working mem
ory, other executive functions, and attention in children with ADHD.
They analyzed data from 25 published research studies on these com
puter training programs to determine what evidence has been provided
to demonstrate their effectiveness in improving working memory and
related ADHD executive functions. The study looked at how well the
training programs produced improvements in tasks similar to those
practiced in the computer training (near transfer). It also examined

whether the training produced any improvements in other functions
and behaviors that are related to the functions the programs claim to im
prove (far transfer) both in the short run and over the longer term. Re
sults found that claims made regarding the benefits of these computer
training programs, including improved academic achievement, cogni
tive improvements, and reduced ADHD symptoms, are not supported
by empirical evidence at this time. A similar study of seven research pa
pers evaluating the Cogmed Working Memory Training program re
ported very similar results; Chacko et al. (2013) concluded that working
memory training programs such as Cogmed cannot be considered a vi
able treatment for youths with ADHD at this time.
An overview assessment of nonmedication treatments for ADHD
was published by two respected American ADHD researchers (Faraone
and Antshel 2014). They applied the strict criteria for identifying evi
dence-based treatments in medicine developed by the University of Ox
ford’s Centre for Evidence-Based Medicine to determine the strength of
the evidence and the magnitude of treatment effects for ADHD medica
tions and nonmedication treatments for reducing ADHD symptoms.
The results of their statistical analysis of existing research data, shown
in Table 11–1, indicate weak effect sizes for most nonpharmacological
treatments. It is important to keep in mind, however, that these results
are based on group data and that for any particular individual, any given
treatment may be significantly more or less effective, for any number of
reasons, than is indicated in data based on studies of groups.
It should be noted, however, that although meta-analyses for behav
ioral interventions did not show significant improvement on core
ADHD treatment when raters were blind to who was taking the treat
ment, another meta-analysis demonstrated that behavioral interven
tions can have positive effects on a range of other outcomes when used
with parents to improve parenting style (Daley et al. 2014).
Additional Supports
For students who have significant difficulty in a particular subject
area(s) and need more remedial tutoring than their school can provide,
many have found the Khan Academy (www.khanacademy.org/) to be a
valuable resource. This site provides a wide range of concise presenta
tions on countless topics for students from elementary school through
college. It is free and is available 24/7.
Some parents arrange private tutoring for their son or daughter. Of
ten school administrators or other parents can recommend a local tutor
TABLE 11–1. Magnitude of treatment effects for attention-

deficit/hyperactivity disorder (ADHD)
medications and nonmedication treatments
for reducing ADHD symptoms
Treatment interventions d
Stimulant medication 0.9

Nonstimulant medication 0.7
Restricted elimination diets 0.5
Artificial food color exclusions 0.4
Neurofeedback 0.3
Computer cognitive training 0.175
Behavioral parent training 0.025
Note. Results are reported using Cohen’s d, a statistical measure that yields decimal
fractions to show how much effect a treatment has in comparison to another treatment
or to a nontreatment. A d of 0.2 is considered small, and 0.5 is considered medium. A
d of 0.8 indicates a large, significant difference.
Source. Data from Faraone and Antshel 2014.
or a moonlighting teacher who is skilled in a specific subject area where

help is needed. Many schools also have peer tutoring available during
the school day.
Two other programs offer valuable resources for parents of children
with ADHD. Understood (www.understood.org/en) is a noncommer
cial online resource that offers a wide range of articles and videos online
to help parents get free, up-to-date, unbiased information to help them in
their efforts to understand and provide resources for their children from
preschool through college who are struggling with attention and/or
learning problems.
Another useful resource is the Parent to Parent Program of CHADD
(www.chadd.org/Training-Events/Parent-to-Parent-Program.aspx),
which offers structured multisession, 14-hour educational experiences
taught by experienced parents of children with ADHD for parents seek
ing help in understanding and dealing with the problems of their chil
dren with ADHD and help in advocating for their children. Sessions are
offered in face-to-face, webinar, and on-demand formats, each for a fee.
Summary
Medications alone are not usually adequate for effective treatment of
ADHD. In this chapter, a wide variety of nonmedication interventions
for ADHD that are often helpful for patients with ADHD and their fam
ilies are described. The most important aspect of treatment is for the cli
nician to provide accurate, science-based information about the nature
of ADHD, how it may change across the life cycle, and how it can most
effectively be treated. Questions frequently asked by parents concerned
about their child with ADHD are presented with suggestions for appro
priate guidance to be adapted and offered by the clinician.
When the patient is a student in elementary or high school, it may be
necessary and helpful for the diagnostic process for the clinician to col
laborate not only with the patient and family but also with the school
staff to establish ongoing communication and arrange possible interven
tions or accommodations to be provided by the school. Practical infor
mation and suggestions about such arrangements are offered in this
chapter along with information about other useful resources. Informa
tion about resources and supports for college and postgraduate students
is also included.
The chapter also furnishes suggestions about the possible usefulness
of supportive psychotherapy, cognitive-behavioral therapy, couple ther
apy, and coaching for ADHD. The chapter concludes with research
based information evaluating various alternative treatments.
12
Treatment
Adaptations for
ADHD With Various
Complications
IN EARLIER CHAPTERS, I HAVE DESCRIBED THE

many differences among persons with attention-deficit/hyperactivity
disorder (ADHD) (Chapter 3), how and why other disorders often co
occur with ADHD (Chapter 7), and practical aspects of treatments for
ADHD (Chapters 10 and 11). In this chapter, I describe how treatments can
and should be adapted for individuals whose ADHD is complicated by
one or more additional problems, such as anxiety, depression, learning
disabilities, or addictions. This chapter is not just about situations where
the patient is diagnosed with an additional disorder. It also recognizes that
sometimes such additional problems need to be addressed in treatment,
even if the patient’s symptoms may not fully meet all the diagnostic crite
ria for the co-occurring disorder. Clinicians do not treat disorders; they
treat individual patients, many of whom are likely to have complications
that need to be taken into account in order to adequately improve the im
pairments related to ADHD and their patients’ overall quality of life.
Effective treatment of the patient with ADHD needs to take into con
sideration not only the identified symptoms but also other learning,
233
psychiatric, and medical difficulties that the patient may experience. In

considering such additional difficulties, it is important for the clinician
to take note of various types of impairment that may be present but that
do not necessarily meet all of the official diagnostic criteria for an addi
tional disorder. If a person tends to be chronically quite anxious or fre
quently discouraged and sad, those problems may have considerable
negative impact on how that person functions and how he or she re
sponds to ADHD treatment, even if the full criteria for a diagnosis of
anxiety disorder or depression are not met.
In this chapter, I also provide brief descriptions of how treatment for
ADHD may be modified to address related problems of particular adult
or child patients. More detailed information about dealing with these
overlapping disorders is provided elsewhere (Brown 2009).
ADHD With Anxiety

For persons with ADHD who also have significant problems with anxi
ety, a treating clinician needs to determine with the patient what is cur
rently causing the most difficulty in daily life: Are the anxiety symptoms
or the ADHD impairments making the most trouble for the patient at the
present time? Which of these difficulties should be addressed first?
Some ongoing conversation between patient and clinician, in explor
atory psychotherapy or in cognitive-behavioral interventions, may be
needed before the possibility of medication treatments can be ade
quately considered. In other instances, when the person has incapacitat
ing worries or acute panic attacks or severe difficulties in falling asleep
or in awakening related to his or her anxiety, starting medication treat
ment with an antianxiety medication such as a benzodiazepine or a se
lective serotonin reuptake inhibitor (SSRI) may be important to stabilize
the patient so that the ADHD symptoms can be dealt with more ade
quately.
In some patients with ADHD, the chronic anxiety is due not so much
to exceptionally strong mechanisms of their brain for generating anxiety
but to their excessively weak executive function abilities to modulate
emotion. The executive function ability to modulate anxiety is that ca
pacity to say to oneself, “Yes, this looks like it could be scary or embar
rassing or painful right now, but it may not be that big a deal! Calm down
and look at the larger picture; it’s possible that this may not turn out to be
as big a problem as I was imagining.” The capacity to modulate anxiety
this way is an example of what is sometimes spoken of as “top-down”
control of emotion—use of higher cognitive functions to respond to
“bottom-up” emotional responses that come with too much attention fo
Treatment Adaptations for ADHD With Various Complications 235
cused on fear and worst-case possibilities “from the gut” without ade
quate awareness of the fuller context and of the ways the situation could
be addressed.
At present, ADHD medications are not approved for use in alleviat
ing excessively intense emotion, but a significant number of patients re
port that their ADHD medication helps them to remain more calm and
to be less easily agitated or upset by experiences or thoughts that made
them quite anxious before they were taking the ADHD medication. In
strengthening patients’ other executive functions, the ADHD medica
tion may also be strengthening their ability to modulate their anxiety or
other emotions that prior to medication use were excessively intense or
persistent.
In past years, and sometimes even today, clinicians were oftentimes
reluctant to prescribe ADHD stimulant medications for patients with
serious anxiety because they feared that stimulants would increase
these patients’ anxiety. A recent meta-analysis of stimulant medication
treatment in children with ADHD has challenged the assumption that
stimulants are likely to cause or exacerbate anxiety.
After analyzing 23 studies involving almost 3,000 children with
ADHD, Coughlin et al. (2015) found that treatment with stimulant med
ications for ADHD significantly reduced the risk of anxiety when com
pared with placebo treatment. These data led Coughlin et al. to recognize
that some children do experience anxiety when treated with stimulants,
but significantly more children with ADHD experience a reduction of
anxiety with stimulant treatment. These findings have not yet been rep
licated in adult samples, but clinical experience suggests that patterns
are similar in adult patients with ADHD.
If a patient is reporting seriously disabling anxiety problems, such as
acute panic attacks with persistent worry about having another panic at
tack, or if the anxiety is seriously and frequently disrupting the patient’s
eating or sleeping to the point where the patient is not able to function
adequately during the day, primary consideration should be given to
reducing the acute anxiety before any medication for ADHD is started.
A trial of low dosing of a benzodiazepine may be needed to facilitate
sleep or to provide immediate support for an imminent threat of a panic
attack. Meanwhile, the patient is likely to benefit from some cognitive
behavioral therapy and/or psychotherapy targeted toward reducing the
acute anxiety problems. An SSRI may also be started to reduce the pa
tient’s baseline anxiety level.
However, if a patient is diagnosed with ADHD and reports chronic
anxiety that is not acutely disabling, it may be preferable to discuss with
the patient the possibility of starting an ADHD medication first and sta
bilizing the dose to see if that medication can be tolerated and can be ti
trated to a dose that will significantly improve the ADHD symptoms
while perhaps also helping to reduce the chronic anxiety by improving
top-down executive control. Usually, a longer-acting stimulant medica
tion is less likely to exacerbate anxiety than immediate-release formula
tions. If the patient is willing to do this and the ADHD medication
regimen is adequately stabilized and if there is still persisting difficulty
with anxiety symptoms, the possibility of adding an SSRI to provide
further reduction of anxiety symptoms can be considered.
If a patient with ADHD has considerable difficulty with anxiety in
addition to ADHD impairments, he or she may already be taking med
ications for anxiety that were prescribed prior to his or her seeking eval
uation for ADHD. In that case, it is usually wise to consult with the
clinician who prescribed the antianxiety medication to seek agreement
to have the patient continue with the present antianxiety regimen when
beginning a trial of medication for ADHD. Stopping the antianxiety
medication and then immediately starting an ADHD medication would
make it very difficult to tell whether emerging problems are due to stop
ping the one medication or starting the other.
In any case, the clinician should advise the patient that some people
find ADHD medication makes them a bit more anxious for a time but
the majority of patients find that ADHD medication does not cause in
creased anxiety and that it may actually help to reduce anxiety. The pa
tient should be encouraged to contact the clinician before their next
scheduled visit if there are any significant difficulties or questions.
Medication follow-up with a patient experiencing anxiety should in
clude careful attention to any adverse effects and to the time and cir
cumstances of their occurrence so that the clinician can help the patient
sort out whether the adverse effects experienced result from the medi
cation or from the patient’s anticipation and expectation of such diffi
culties. If any adverse effects seem due to the medication, consideration
should be given to the possibility of reducing the dose versus remaining
at the starting dose for a bit longer to see if the patient’s body becomes
better able to tolerate the medication.
Many patients struggling with anxiety and ADHD also benefit from
cognitive-behavioral treatments. Ramsay (2010) and Ramsay and Ros
tain (2015a, 2015b) have described how cognitive-behavioral techniques
can be helpfully adapted to adults with ADHD and various complica
tions. Szigethy et al. (2012) provide strategies for cognitive-behavioral
treatment of children and adolescents, whereas Alfano and Beidel
(2011) have compiled guidance for treatment of social anxiety in chil
dren and adolescents and young adults in a variety of situations. Al
though not specifically focused on patients with ADHD, both of these

books provide cognitive-behavioral treatment strategies that can be
adapted for children and adolescents with ADHD and other disorders.
ADHD With Depression

If a patient presents with acute symptoms of major depression such as
significant suicidal ideation, suicidal gestures, or suicidal intent, prior
ity must be given to treating the acute depression. Likewise, if there are
vegetative signs such as severe chronic difficulty falling asleep, persis
tently recurrent intermittent awakening, early morning awakening
without ability to return to sleep, or severe anorexia with significant
weight loss, the depression should be given treatment priority. Any
such constellation of symptoms requires immediate measures to pro
vide support and to attend to concerns regarding patient safety. Usually,
such symptoms require immediate initiation of an antidepressant med
ication with therapeutic exploration of precipitating factors, evaluation
of family or other social support, and possibly a brief hospitalization.
Only after such acute symptoms are adequately stabilized is it sensible
to initiate treatment targeting ADHD impairments. Yet this is not to say
that the ADHD impairments present should be ignored; addressing
these may eventually help to support the patient’s recovery.
However, if a patient with ADHD has complaints of nonacute symp
toms of major depressive disorder or persistent depressive disorder
(dysthymia), the clinician may want to consider beginning treatment
with a stimulant medication to see if that might help to alleviate some of
the depressive symptoms. Sometimes depressive symptoms in persons
with ADHD are reactive to their continuing frustration and demoraliza
tion resulting from their untreated or inadequately treated impairments
related to ADHD.
If there is not significant improvement in that patient’s depressive
symptoms once the dosage of stimulant medication has been adequately ti
trated and stabilized, an SSRI or other antidepressant medication might be
added to target the depressive symptoms more directly. This sequence of
stimulant treatment first provides the patient with a trial of a medication
that might have some immediate beneficial effects; this can be important to
the patient, who otherwise may be waiting 4–6 weeks before any antide
pressant medication is likely to become effective. Throughout the early
weeks of treatment, psychotherapeutic sessions can provide an important
resource for stabilization as well as an opportunity to gain a more adequate
understanding of the respective contributions of the ADHD and the de
pressive symptoms to the patient’s impairments and misery.
ADHD With Learning Problems

in Reading, Math, and/or
Written Expression
As discussed in Chapter 7 (“How and Why Other Disorders Often Co
occur With ADHD”), there are significant overlaps between ADHD and
learning disorders, but also significant differences. If a patient is referred
with complaints of difficulties with reading, math, or written expression, it
is advisable to investigate possible ADHD-related impairments in areas
such as the ability to sustain attention, to shift focus, to complete academic
tasks in a reasonable time, and to utilize working memory, as well as spe
cific impairments in academic skills. Likewise, if a patient presents with
concerns about ADHD, it is important to get a good history of his or her
functioning in school, including asking about notable difficulties with read
ing, math, and/or writing at various points in the patient’s schooling.
Sometimes it is clear that the primary problem is with ADHD
related impairments and that academic skills are not and never have
been a problem. Yet for many persons with ADHD who are struggling in
school, there is also an underlying problem with reading, math, and/or
writing that needs to be assessed as well. If the patient reports such skills
difficulties, it may be useful to supplement the usual ADHD assessment
with a psychoeducational evaluation that includes a normed IQ test
such as one of the following:
• Wechsler Intelligence Scale for Children (5th Edition [WISC-V], for

children ages 6–16 years) (Wechsler 2014)
• Wechsler Adult Intelligence Scale (4th Edition [WAIS-IV], for teens or
adults age 16 and older) (Wechsler 2008)
• Woodcock-Johnson IV Tests of Cognitive Abilities (WJIV; for ages 2–
90 years) (Woodcock-Johnson 2016a)
In addition to such a measure of cognitive abilities, the psychoedu

cational evaluation should also include an individually administered
academic achievement test such as one of the following:
• Wechsler Individual Achievement Test (3rd Edition [WIAT-III], for

ages 4–50 years) (Wechsler 2009)
• Woodcock-Johnson IV Tests of Achievement (WJIV, for ages 2–90 years)
(Woodcock-Johnson 2016b)
Such tests, usually administered, scored, and interpreted by a school

psychologist or a clinical psychologist, provide standardized measures
of ability and academic achievement scored for age and grade-level

comparisons. Score reports provide comparisons between ability and
achievement for the variety of specific abilities tested. In combination
with school achievement data, they are usually sufficient to identify stu
dents who suffer from specific learning disorders.
For students with ADHD, with or without a specific learning disor
der, index scores on the Wechsler IQ tests typically, though not always,
show relative strengths in verbal comprehension and/or perceptual
reasoning, with relative weaknesses in working memory and/or pro
cessing speed (Brown et al. 2009, 2011a; Kennedy et al. 2016). For stu
dents who also have a specific learning disorder, achievement scores in
the impaired skills will usually, though not always, be 1.5 or more stan
dard deviations below scores on the relevant ability measures.
However, such discrepancies alone may not be sufficient for diagno
sis of a learning disorder in some settings. Some school systems do not
use the IQ-achievement discrepancy model for identifying students
with learning disabilities; instead they utilize a response-to-instruction
model that is more directly tied to the curriculum utilized in the school.
The response-to-instruction approach remains somewhat controversial
(Reynolds and Shaywitz 2009).
Two additional measures may be helpful in some cases. For identi
fying students in high school or beyond who need extended time for
taking standardized tests, the Nelson-Denny Reading Test (Brown et al.
1993) allows comparison of how the student performs on reading tasks
with standard time versus extended time. In conjunction with ability
and achievement testing, this measure may be helpful in arranging for
the student to receive extended time for standardized testing.
For students who have extraordinary difficulty in learning a foreign
language, the Modern Language Aptitude Test (Carroll and Sapon 2002)
allows comparison with norms for high school and college students;
this measure can be helpful to school or standardized testing authorities
for assessing whether the student’s impairments in learning a foreign
language warrant a waiver from school requirements for taking courses
in foreign language.
Assessment for a specific learning disorder does not usually require
the patient’s undergoing a full neuropsychological evaluation, which
involves many more tests and much higher costs. If a patient is identi
fied as having a specific learning disorder in reading, math, and/or
written expression, it is quite likely that there will also be evidence of
ADHD-related impairments that should be treated. In Chapter 7, I de
scribe the multiple facets of ADHD that overlap with learning disor
ders. Even if the student with learning problems does not manifest
severe ADHD-related impairments, there is a good reason to try ADHD

medications in order to optimize the student’s ability to participate and
utilize remedial tutoring for his or her specific learning impairments. It
should be noted that ADHD medication alone is unlikely to be sufficient
for remediation of a specific learning disorder. Usually, remedial in
struction in the specific areas of weakness is needed in addition to med
ication.
The other domain of intervention for students with significant learn
ing problems is accommodations. Information about the types of ac
commodations that may be provided and procedures for arranging
them is provided in Chapter 11 (“Practical Aspects of Nonmedication
Interventions for ADHD”).
ADHD With Emotional Regulation

and Mood Problems
Problems with managing emotions are not uncommon in persons with
ADHD, but they are not characteristic of all who have been diagnosed
with ADHD. An overview of relevant research studies found that 25%–
45% of children with ADHD and 30%–70% of adults with ADHD tend
to have chronic problems with dysregulation of their emotions (Vidal-
Ribas et al. 2016). Shaw et al. (2014) describe “emotional dysregulation” as
a pattern of emotional expressions that are excessive in regard to social
norms and inappropriate to context; involve rapid, poorly controlled shifts
in emotions (lability); and/or involve unusual and excessive focus of atten
tion on emotional stimuli. They suggest that this is in contrast to adaptive
“emotional regulation,” the ability of an individual to deal flexibly and
adaptively with emotionally arousing stimuli in ways that do not defeat his
or her own interests. Obviously, expectations for self-regulation of emo
tions vary according to the person’s age and developmental level.
Most research in this area thus far has focused on emotional dysreg
ulation manifest in irritability or aggressive behavior. These two forms
of emotional dysregulation are, in many cases, significant aspects of a
variety of different diagnoses, such as oppositional defiant disorder, bi
polar disorder, major depressive disorder (especially in children or ado
lescents), generalized anxiety disorder, disruptive mood dysregulation
disorder, conduct disorder (CD), and intermittent explosive disorder.
If a patient with ADHD presents with significant problems of
chronic irritability or excessively aggressive behavior, it is important for
the clinician to gather information about the history and circumstances
of those behaviors. If the patient is already taking medication for ADHD
and these mood problems seemed to have their initial onset with the use
of that medication, it may be that the ADHD medication itself is contrib
uting to or precipitating the mood problems. In inquiring about this
possibility, it is important to query about the time of day and the situa
tions in which the mood problems are emerging. If the problems occur
shortly after the ADHD medication is ingested and then improve when
the medication is expected to be wearing off, it may be that the dose of
the ADHD medication is too high for that patient or that the patient is
simply not able to tolerate that drug.
However, if the patient is not reporting mood problems throughout
the time the medication is active and does experience excessive moodi
ness around the time the medication is wearing off, that may be a sign of
rebound, in which the moodiness is a reaction to an excessively rapid
downward trajectory of the medication’s effects such that the person is
“crashing.” In that case, the mood problem may be resolved by adding
a small booster dose to slow down the excessively rapid declining tra
jectory of the medication’s effects. Sometimes rebound moodiness is
characterized by heightened irritability, sometimes by anxious restless
ness, and sometimes by depressive mood symptoms.
If the patient is presenting with a history of mood problems that did
not start in response to ADHD medication, then diagnostic inquiry
should focus on what kind of mood problems occur, how often and for
how long these mood problems have been occurring, and what circum
stances make them better or worse. It may also be helpful to inquire as to
whether any blood-related relatives have shown a similar pattern of
mood problems so that both genetic and environmental etiological fac
tors can be taken into account.
If the patient with ADHD has a long history of excessive irritability,
low frustration tolerance, frequent or protracted temper outbursts over
relatively trivial matters, or excessively aggressive verbal or physical ac
tions that are apparently not due to excessive drinking of alcohol, other
drug use, or environmental provocations (e.g., household members or
others deliberately provoking), a trial of stimulant medication may be a
reasonable first step. Both stimulant medication and atomoxetine have
been shown to be effective in alleviating core symptoms of ADHD but
also often have beneficial effects on emotional dysregulation. Shaw et al.
(2014) have reviewed the evidence and recommend these ADHD med
ications as first-line treatment for emotional dysregulation, possibly
with accompanying behavioral treatments. Another option with some
empirical support is guanfacine in combination with a stimulant. This
combination has been approved by the U.S. Food and Drug Adminis
tration (FDA) for such difficulties.
For patients with ADHD and depression who have prominent emo
tional dysregulation, Shaw et al. (2014) suggest that stimulant medica
tion combined with an SSRI may be a reasonable choice. However, there
is reason to be cautious in use of antidepressant medications with child,
adolescent, or young adult patients who manifest more severe mood
symptoms, such as signs of major depression and anxiety, and episodic
manic symptoms, such as sleep disturbances, anger or irritability, in
creased energy, or rapid mood fluctuations. Rios et al. (2015), in their
study of early stages of bipolar disorder, noted an emerging body of ev
idence that treatment with antidepressants, tricyclic antidepressants or
SSRIs, may precipitate or exacerbate suicidality and manic symptoms,
possibly reducing age at onset of mania. This risk warrants careful mon
itoring of patient response when an antidepressant is being started, es
pecially in the early weeks.
Rios et al. (2015) also noted that acute treatment with stimulants may
stimulate mania in persons in the prodromal stage of bipolar disorder.
However, Carlson and Meyer (2009) emphasized the importance of
treating ADHD impairments in patients with significant mood prob
lems. They suggested that if a patient clearly seems to have mania or a
bipolar disorder, treatment should begin with a mood stabilizer and/or
an atypical antipsychotic medication, with medication treatment for
ADHD added after the mood problems are stabilized if the patient re
mains impaired by ADHD symptoms. In situations where a mood dis
order diagnosis is less clear-cut, Carlson and Meyer described beginning
with ADHD medication treatment as acceptable so long as the clinician
is alert to possible disinhibition resulting from stimulant medication.
Joshi and Wozniak (2015) emphasize that medication treatment of
ADHD should not be addressed in cases of bipolar disorder until after
the bipolar symptoms have been stabilized. However, they also recog
nize that in a mood-stabilized youth with bipolar disorder, ADHD
symptoms with their impact on social, academic, and emotional func
tioning often become the next most severe complaint presented by the
patient.
ADHD With Sleep and Arousal

Problems
Many children, adolescents, and adults with ADHD report chronic dif
ficulties with sleep and arousal, often from early childhood. There are
three types of difficulties with sleep and arousal that are commonly re
ported by persons with ADHD and their family members:
• Difficulty falling asleep and sustaining sleep

• Difficulty awakening
• Difficulty maintaining adequate alertness for activities during the
day
For many children and some adults, it is often difficult to stop activ
ities of the day at a reasonable time. Some children with ADHD are
chronically oppositional and tend to resist directions to prepare for bed
much as they resist many other directions from their parents. Many chil
dren and adults with ADHD find it very difficult to stop their evening
activities and get settled into bed at a reasonable time even when they
recognize the need to do so. Sometimes the problem with older children,
adolescents, and adults is staying up late to finish homework or reports
they are expected to hand in the next morning at school or work. More
often, delays in getting into bed are due to their reluctance to stop en
gaging in favored activities such as watching television, playing video
games, texting or interacting on social media with friends, surfing the
Internet, or pleasure reading.
In many instances, the individual may get into bed but continue to
engage in these activities that interest him or her. Sometimes adoles
cents or young adults will get into bed, fall asleep, and then be awak
ened by friends who text them at late hours and whom they want to
talk with or feel obliged to interact with until very late. Many of those
who are chronically delayed in getting to sleep report, “I really want to
get to sleep earlier, but most nights I just can’t shut my head off, so I
have to busy myself with something else until I’m exhausted. I can fall
asleep easily at that point, but often that doesn’t leave me many hours
to sleep.”
Some individuals with ADHD report that they struggle on many
nights with getting to sleep because of thinking about things that sadden
or worry them; they are unable to dismiss those disturbing thoughts and
associated feelings when trying to get to sleep. At such times, they may
be flooded by sadness, worry, or guilt about something that has recently
happened or something they expect to happen soon.
When onset of sleep has been delayed, regardless of the reason, total
sleep time is reduced. For those who are required to get up so they can
be on time for school or work, this can create significant problems, es
pecially if sleep delays tend to be long and chronic.
A common result of chronic difficulty in getting to sleep is chronic
difficulty in awakening on schedule. Some persons with ADHD report
chronic difficulty in awakening even when they have had an ample
quantity of decent sleep. Many with ADHD report that every day be
gins with a protracted, very frustrating struggle between themselves

and a family member who tries to awaken them or between themselves
and their alarm clock, which they repeatedly reset for snooze until they
realize that they are late or are going to be late getting to wherever they
need to be. Chronic lateness to work or school is a common problem
among individuals with ADHD.
Yet persons with ADHD who are often late to school or work, and
even those with ADHD who are rarely late, often report chronic prob
lems with excessive daytime sleepiness. Typically, their struggle with
staying alert does not cause difficulties while they are physically active,
talking a lot, or engaged in activities in which they have strong interest.
More commonly, they report feeling drowsy, often barely able to keep
their eyes open, when they have to sit still to listen to classroom instruc
tion or to do required reading. Some report that often they actually fall
asleep in such situations, even though they may be fully alert moments
later when they can get up to become more active.
Baird et al. (2012), Brown and McMullen (2001), Owens et al. (2009,
2013), Cortese et al. (2013a), and Philipsen et al. (2006) have reviewed
details about research on these issues with sleep in individuals with
ADHD. They have also described physiological mechanisms likely to
underlie these sleep difficulties and make them more common in chil
dren and adults with ADHD. Here I will simply mention a few addi
tional physiological factors that may contribute to sleep problems in
persons with ADHD. Some children with ADHD have chronic problems
with sleep-disordered breathing, sometimes due to enlarged tonsils
and/or adenoids. Some children and adults have restless legs syn
drome, and some adolescents and adults experience chronic fatigue as a
result of undiagnosed obstructive sleep apnea. Each of these three prob
lems is usually diagnosed with polysomnography after a clinical inter
view.
Interventions for patients whose ADHD is accompanied by sleep
problems usually begin with the clinician taking a careful history of the
nature and pattern of the sleep problems, being careful to inquire and
note specifically what time the person usually gets into bed with intent
to sleep, how long it usually takes to get to sleep, whether the person ex
periences intermittent awakenings, how difficult it usually is for him or
her to wake up and get started with the morning routine, and whether
the person or his or her family notices any problems with excessive day
time sleepiness. For children, inquiry should also be made about prob
lems with bad dreams or enuresis.
Once an adequate history has been obtained, and the clinician has
ruled out the possibility that some of the reported insomnia may be due
to stimulant medication administered too late in the day, some discus

sion of sleep hygiene is usually appropriate. This involves talking with
the patient—and, for children, with the parents—about the importance
of trying to maintain a stable, reasonable bedtime, a calming tapering
down of activities before bedtime, avoidance of television and other
electronics for at least an hour before bedtime, and consistency in get
ting out of bed at the same time each morning.
While working to address sleep problems, the patient or parents
should be encouraged to maintain a sleep diary in which they note time
of getting to bed, time of getting to sleep, number of awakenings, diffi
culties in awakening, episodes of excessive daytime sleepiness, and so
forth. It can be helpful for the clinician to look at and discuss efforts of
the patient or parents to improve the quality of sleep hygiene.
Another behavioral strategy is teaching progressive muscle relax
ation, in which the patient is taught to maintain yoga-style deep breath
ing while doing a series of bilateral isometric contractions of selected
muscle groups, followed immediately with maximal relaxation of that
muscle group. Gradually, the patient shifts from one specific muscle
group to another, starting with the feet, then moving to repeat the se
quence of several maximal isometric contractions, each followed by
maximal relaxation of those same muscles. After a few repetitions of one
group, the isometric contractions and relaxation progress to calves,
thighs, abdominals, shoulders and arms, neck, and face. If necessary,
this whole sequence may be repeated several times. It can also be ac
companied by development of relaxing visual imagery.
If these behavioral strategies are not adequate, the clinician may
want to consider use of medications. Prince and Wilens (2009) have sug
gested that melatonin (1–3 mg for children; 5–10 mg for adults) taken
about an hour before bedtime may be helpful. If that is not successful,
they suggest clonidine (0.1–0.3 mg), diphenhydramine (25–50 mg), tra
zodone (25–50 mg), or mirtazapine (3.75–15 mg).
ADHD With Oppositionality

and Aggression
About 10%–12% of the general population of children in the United
States are found to have oppositional defiant disorder (ODD), a pattern of
behavior characterized not only by angry, irritable mood but also by ar
gumentative/defiant and/or vindictive behavior (Merikangas et al.
2010; Nock et al. 2007). Among children with ADHD, especially those
with combined-type ADHD, the estimated prevalence of ODD is much
higher, ranging from 35% to 50%. A study of ODD in adults yielded an

estimated prevalence of about 12% (Harpold et al. 2007).
ODD usually onsets at about 12 years, but this pattern of severe,
chronic oppositionality and irritability sometimes appears in preschool
ers who greatly exceed the oppositional and defiant behavior typical of
most of their peers (Burke et al. 2010). For most of those affected, ODD
symptoms usually taper down as they move through adolescence. More
than 70% of those diagnosed with ODD no longer have behaviors and
symptoms that meet diagnostic criteria by the time they are 18 years old,
and most never qualify for diagnosis of CD.
Conduct disorder is a pattern of seriously delinquent behavior that in
volves aggression to people or animals, destruction of property, deceit
fulness or theft, and other serious rule violations. Prevalence of CD is
estimated at about 6% in the general population of adolescents.
Among that smaller number of children who qualify for a CD diag
nosis, three characteristics are often found: deficient empathy, height
ened threat sensitivity, and deficient decision making (Blair et al. 2014).
Although many individuals with CD demonstrate deficient empathy
from an early age with little indication of ability to recognize distress in
peers and little remorse for hurting others, there is a subgroup of those
with CD who do demonstrate empathy and whose functioning tends to
be characterized by increased anxiety and hypersensitivity to threat;
they often expect aggression from others to be directed at them (Blair et
al. 2014).
Treatment of CD with cognitive-behavioral therapy may be helpful
for addressing underlying anxiety. Encouraging parents to reduce stress
at home, to use supportive rather than harsh limit setting, to monitor the
child’s activities, and to utilize other needed supportive services may
also be helpful.
Stimulant medications are often helpful in alleviating excessive im
pulsivity and aggression. Usually, longer-acting formulations of meth
ylphenidate or amphetamine are preferable to minimize need for
administration of multiple doses each day and to reduce the likelihood
of inappropriate use or diversion. Newcorn et al. (2009) and Wilens et al.
(2015) have reported that guanfacine, a longer-acting, less sedating type
of α2-adrenergic agent, is often effective in treating symptoms of hyper
activity, impulsivity, and aggression in those with ADHD. The FDA has
approved use of guanfacine (1–4 mg) for monotherapy treatment of
ADHD and in combination with stimulant medication. This combina
tion may be particularly useful for treating patients with ADHD accom
panied by ODD or CD symptoms. Newcorn et al. (2009) also noted that
lithium, other mood stabilizers, and atypical antipsychotics have been
demonstrated to be helpful for chronic problems with aggression, al

though these medications require very careful considerations of risks
and longer-term adverse effects.
ADHD With Obsessional

and/or Compulsive Problems
Little research has been published regarding the incidence of obses
sional or compulsive problems in persons with ADHD. Prevalence of
obsessive-compulsive disorder (OCD) in the general population has
been estimated at about 2.5% in adults and about 2%–4% in children.
Sometimes OCD problems arise during childhood, with an average age
at onset of about 10 years. For others, onset of OCD symptoms is usually
not until the young adult years (onset at about 19 years on average),
with symptoms having developed by at least age 25 years in 65% of
those affected (Geller and Brown 2009).
For some individuals with OCD, the difficulties are with persistent
obsessional thoughts that are disturbing. Individuals get stuck in re
peatedly thinking about certain worries or disturbing images that they
consider excessive or unreasonable, but they are often unable to clear
such thoughts from their minds. An example would be recurrent worry
that they might get bad grades in school, lose their job, or be abandoned
by their parent or partner. Another example might be recurrent images
of a loved one being fatally injured in a motor vehicle accident or of
one’s home being invaded by a robber.
Others are chronically caught up in feeling that they must perform
certain actions, otherwise something very unpleasant will happen or
they will simply not be able to relax and feel “just right.” These compul
sive behaviors might include checking multiple times to be sure they
have locked a door or turned off a light or paid a particular bill. Some
have no issues with checking, but they feel an almost irresistible urge to
rearrange things to make them symmetrical or to walk into a room and
then immediately walk out and then walk in again.
For many years, OCD was classified as an anxiety disorder because
it was assumed that obsessional thoughts and compulsive behaviors
were simply irrational actions to ward off or reduce anxiety. OCD was
removed from the classification of anxiety disorders in DSM-5 (Ameri
can Psychiatric Association 2013), and a new category was created,
obsessive-compulsive and related disorders, which includes not only OCD
but also disorders of hoarding, hair pulling, skin picking, and body im
age (i.e., persistent feelings that one has certain bodily features that are
defective, although they may not be noticeable to anyone else). Each of

these disorders has its own distinctive characteristics, but all involve
some aspects of struggling with perseverative thoughts or compulsive
behaviors that are maladaptive, and all seem to involve somewhat re
lated pathophysiology. Phillips and Stein (2015) have edited a book that
provides careful descriptions of these related disorders as well as some
guidance on effective treatment approaches for each.
Because many who suffer from OCD or related disorders feel ashamed
of these difficulties, which they recognize as irrational, they may be hes
itant to mention such problems to a clinician even while they may freely
describe their ADHD, depression, or anxiety symptoms. In an initial eval
uation, it may be helpful for the clinician to inquire about excessive wor
ries and give some specific examples of the many varieties of obsessions
and compulsions.
Three types of OCD-related problems that often are reported by pa
tients with ADHD are hoarding of stuff, recurrent thoughts of failing at
school or career, and excessive perfectionism in written expression.
Hoarding may be an extension of the person’s difficulty in organizing
his or her stuff and prioritizing to determine which things are important
to save and which should be discarded. Recurrent thoughts of oneself as
destined to fail in school or career or relationships may be a conse
quence of repeated experiences of failure due to ADHD-related impair
ments of executive functions.
Excessive perfectionism in written expression is often manifest in a
felt need to get the first sentence of any essay or report to sound “just
right” before the second sentence can be written, and then to perfect that
second sentence to sound just right before the third sentence can be
started, and so on. This tedious approach to written expression may be
an exaggerated compensation for fears of being seen as totally incom
petent by potential readers.
For some patients with ADHD, taking stimulant medications may
intensify their OCD tendencies, making them much more perfectionis
tic or more fearful of being exposed as incompetent than they would be
without such medication. If this occurs, the clinician should assess the
situation and reduce the dose or change the medication.
If such OCD tendencies were present prior to the patient taking stim
ulant medication or if the ADHD medication is not effective when the
dose is reduced or an alternative medication is tried, it may be advisable
to consider a trial of an SSRI or clomipramine. While those medications
are not effective with all patients who struggle with OCD-related dis
orders, they may be quite helpful with some such difficulties. The Phil
lips and Stein (2015) book provides useful guidance on the variety of
cognitive-behavioral and/or medication treatments that have been

demonstrated to be helpful for the various disorders in this category. Al
though not explicitly addressing ADHD, Egan et al. (2014) have pub
lished descriptions of cognitive-behavioral treatments that may be
helpful with certain types of excessive perfectionism that may be seen
with ADHD.
ADHD With Substance Use Problems

In Chapter 7, there is a description of how and why substance use dis
orders frequently occur in individuals with ADHD. In this section of
this chapter, the focus is on how treatment should be adapted to provide
adequate care for patients who are experiencing ADHD and varying de
grees of “troublesome use” of substances like alcohol, marijuana, pre
scription drugs, cocaine, or heroin. This section also includes some
suggestions on how to reduce misuse and diversion of medications
used to treat ADHD.
Harstad and Levy (2014) noted that misuse and diversion of stimu
lant medications are more widespread than problems with abuse or ad
diction. Misuse refers to using medications not prescribed for the
individual or using medications in larger or more frequent doses than
prescribed. Diversion refers to transfer of a medication to someone other
than the person for whom it was prescribed. The most common reasons
reported for misuse of stimulant medications are for do intensive last
minute studying before an exam, to improve recall while taking an exam,
to pull “all-nighters” to complete assignments, to experiment, to inten
sify excitement for partying, or to minimize drowsiness from heavy
drinking (a practice that can lead to dangerously excessive intake).
Wilens et al. (2008) reviewed 21 studies and found that rates of non
prescribed stimulant use ranged from 5% to 9% among grade school
and high school students and from 5% to 35% in college-age individu
als. These percentages are estimates of how many students engaged in
misuse of stimulants during the preceding year; they do not differenti
ate between those who misused once and those who misused repeat
edly.
Clinicians who prescribe stimulant medications should educate pa
tients and parents about the importance of keeping these medications
secure, not having anyone carrying pills around in a backpack, and not
leaving them in locations such as a bathroom medicine cabinet or on the
kitchen counter where visitors can easily steal them. College students,
especially those living in a dormitory, should be cautioned not only to
keep their medication supply secure but also to consistently resist any
pleas from friends or acquaintances who want to buy or borrow some of

their stimulant medication. They need to do this not only to protect
themselves from running out of medication early but also to avoid vio
lating federal laws that consider distribution of any Schedule II drug to
someone else to be “dealing,” regardless of whether any money is in
volved or not.
Clinicians should also monitor carefully any patient who repeatedly
requests a new prescription for the prescribed stimulant earlier than he
or she should be running out of it. This may reflect a problem of care
lessness in caring for the medication or deliberate misuse. Clinicians
should also talk sensitively with patients who request an increase in
their dose or in their frequency of dosing to determine whether such an
increase is actually appropriate and needed to provide adequate cover
age for this patient or is perhaps an early stage of excessive use that may
become problematic and require further clinical exploration.
Incidence of substance use disorders in adults with ADHD is approx
imately three times the incidence of substance use disorders in the gen
eral population. Often substance use problems begin during early or
middle adolescence and increase in severity during late adolescence, es
pecially in adolescents with ADHD. Most often these substance use prob
lems are not with stimulant medications; usually they are with nicotine,
marijuana or hashish, and/or alcohol. Like others in the general popula
tion, some adolescents and adults with ADHD also struggle with unpre
scribed use of prescription drugs such as antianxiety medications like
Xanax or Klonopin or opiate painkillers such as Percocet or OxyContin,
or with cocaine or heroin.
When the clinician is evaluating adolescents or adults for ADHD, it
is very important to inquire about the individual’s past and current his
tory of using cigarettes, alcohol, marijuana or hashish, prescription
drugs, cocaine, ecstasy, MDMA (3,4-methylenedioxymethamphet
amine), psychedelic drugs, and heroin. When the patient is an adoles
cent or young adult being seen with his or her parents, the parents
should be asked about whether they believe that their son or daughter
has had any problems with drug or alcohol use. If they indicate yes, the
clinician should elicit a description. However, adolescents and young
adults should not be asked about alcohol or drug use in the presence of
their parents. That inquiry should be done privately in a nonjudgmental
way with reassurance that the clinician will not disclose this informa
tion to the parents. It should include specific queries about what drugs,
what quantities, and what sort of reactions the patient had to them. The
clinician should also keep in mind that such reports from patients are
usually underestimates. A useful resource for clinicians not familiar
with street terms for various drugs is Buzzed: The Straight Facts About the
Most Used and Abused Drugs From Alcohol to Ecstasy (Kuhn et al. 2008).
If a patient diagnosed with ADHD is found to have a recent or cur
rent problem with alcohol or drug use, it is extremely important to take
this into account in assessment and treatment planning. Persons with
substance use problems are not all alike, and they do not all have the
same needs for particular types of treatment. The so-called addictive
personality is a myth. Individuals who become involved in substance
use that reaches the level of a disorder vary considerably in their age,
race, ethnic background, social class, and personality characteristics.
Maia Szalavitz (2016), who herself experienced and recovered from
serious problems with drug addiction, has provided, in Unbroken Brain:
A Revolutionary New Way of Understanding Addiction, an articulate de
scription of the complex diversity among persons suffering from sub
stance use disorders and their struggles in treatment and recovery:
Children who ultimately develop addictions tend to be outliers....[S]ome

stand out because they are antisocial and callous...but others stand out
because they are overly moralistic and sensitive. While those who are the
most impulsive and eager to try new things are at highest risk, the odds
of addiction are also elevated in those who are compulsive and fear nov
elty. It is extremes of personality and temperament—some of which are
associated with talents, not deficits—that elevates risk. Giftedness and
high IQ, for instance, are linked with higher rates of illegal drug use than
having average intelligence. (p. 59)
Any efforts to provide help and support for persons with a sub
stance use disorder should be guided by recognition that substance use
disorders are not fundamentally fueled by a quest for pleasure but by
desperate efforts to find relief from pain and stress that the individual
has not been able to cope with adequately. This is important because it
makes clear why curtailing a substance use disorder initially brings not
just relief but also intensification of whatever emotional burdens that
person has been trying to keep at bay by excessive use of the problem
atic substance. Initial pride and pleasure in stopping problematic use is
often quickly challenged by fears of being overwhelmed by hidden vul
nerabilities.
Many treatment programs for persons with substance use disorders
are based on the assumption that persons with substance use disorders
must “hit bottom” before they can recover—that they will be motivated to
stop their addictive behavior only when they have suffered painful loss of
virtually all that is valuable to them. This view often encourages parents
and other family members to adhere to a “tough love” approach in deal
ing with the addicted person. This model, often promulgated in 12-step
programs such as Alcoholics Anonymous (AA) and Narcotics Anony
mous, typically includes the notion that the goal of treatment must be
achieving and sustaining total abstinence from the problematic sub
stance. Another premise of such programs is that recovery can begin only
when one admits to being totally powerless to overcome addiction and to
needing to invoke the help of a higher power, which may be prayer and/
or continuing attendance at AA or a similar support group. This approach
has helped a very large number of people to find and sustain recovery
from a substance use disorder, but there are also many for whom it does
not work effectively and for whom it is a barrier to recovery.
An alternative approach to helping persons with a substance use
disorder is harm reduction, as summarized in Harm Reduction: Pragmatic
Strategies for Managing High-Risk Behaviors, edited by G. Alan Marlatt
(1998). This approach acknowledges total abstinence as a worthy goal, but
it accepts alternatives that reduce harm. It is a gradual “step-down” ap
proach that encourages those engaged in high-risk behaviors to take it “one
step at a time” to reduce the harmful consequences of their substance use.
Harm reduction approaches do not wait for an individual to “hit
bottom”; they try to encourage individuals to reduce their problematic
use to less destructive levels so they can protect whatever resources they
have. Szalavitz (2016) emphasizes the potential benefit of this approach:
[P]eople are actually more likely to recover when they still have jobs,
family, and greater ties to mainstream society, not less. Indeed, the more
“social capital” someone has—friends, education, employment, job con
tacts and other knowledge that promotes links to the conventional
world—the more likely recovery is. (p. 184)
Over the past 20 years, there have been many changes in scientific
understanding of addiction and its treatment. Carroll and Rounsaville
(2006) have described how and why inpatient treatment for substance
use disorders is now much less frequently used. It has been replaced by
outpatient and intensive day treatment approaches that seek to help pa
tients to learn to cope with their addiction in the context of their own
community. It is now known that brief behavioral therapies with a mo
tivational approach are more effective for most individuals with sub
stance use disorders. These approaches typically include
assessment and feedback on substance use and consequences; an empathic,

nonjudgmental stance by the clinician that emphasizes individual choice
and autonomy; acceptance of client ambivalence about his problem behav
ior; and emphasis on a range of client goals that may or may not include for
mal treatment or abstinence. (Carroll and Rounsaville 2006, p. 227)
If a clinician is evaluating a patient with ADHD and finds that the pa
tient has a current substance use disorder that is significantly impairing
functioning, the clinician needs to determine with the patient whether
the substance use disorder is at a point where involvement in specialized
treatment such as motivational behavioral therapy or intensive outpa
tient treatment may be needed. For more acute problems, detoxification
or residential treatment may be needed. Medication treatment for
ADHD is not likely to be effective in such circumstances and may, in fact,
exacerbate the problem, although it may be quite helpful once the acute
phase is resolved.
If a patient with significant impairment from ADHD has a pattern of
occasional use of alcohol or marijuana that is not significantly disrupt
ing his or her functioning, a cautious trial of medication treatment for
ADHD may be quite appropriate. In such situations, longer-acting for
mulations of stimulants or nonstimulant medications for ADHD are less
likely to be misused and more likely to be effective than are preparations
with medium duration of action or immediate-release preparations
(Wilens and Morrison 2015).
If a clinician agrees to undertake such a treatment plan, it is impor
tant to provide close monitoring of both medication use and the pattern
of alcohol or marijuana use, including not only frequencies but also
quantities. The clinician, in such situations, needs to avoid the role of
“enforcer” for reducing alcohol or marijuana use. Techniques of moti
vational interviewing described by Miller and Rollnick (2013) can be
helpful in respecting the patient’s ambivalence and autonomy.
With such support, many patients with ADHD are able to maintain a
helpful regimen of medication treatment for their ADHD while holding
their use of marijuana to low doses a couple of times a week and their
consumption of alcohol to a reasonable level. However, for some pa
tients, it is extremely difficult to avoid resuming excessive use, in which
case the medication for ADHD is likely to become ineffective and they
are likely to return to a situation where they have insufficient motiva
tion to do tasks important for their success.
ADHD With Asperger Syndrome or

Other Autism Spectrum Difficulties
As mentioned in Chapter 7, the current diagnostic manual, DSM-5, does
not include the diagnosis of Asperger syndrome (AS); it incorporates
this syndrome into the autism spectrum. However, that change remains
controversial, and many clinicians feel that it is more useful to continue
to use the AS diagnosis while the matter is further researched. In this

section, following some brief comments on adapting treatment of
ADHD for individuals with other types of autism spectrum impair
ments, I focus primarily on how treatment for ADHD can be adapted for
those whose ADHD is accompanied by the impairments of AS.
The impairments of children with classical autism spectrum disor
der (ASD) are usually recognized by their parents within the first 2 years
of life (Volkmar et al. 2008). Concerns about delays in speech and lan
guage development usually appear earliest, followed by concerns about
delays in social responsiveness and communication, which are gener
ally recognized as being noticeable sometime before the child’s second
birthday and may include diminished eye contact, limited interest in in
teracting with others, reduced smiling and looking at others, and pref
erence for being alone.
Extensive research over the past 20 years emphasizes the importance
of early diagnostic assessment (Bishop et al. 2008), early intensive natu
ralistic behavioral intervention for young children with ASD (Koegel et
al. 2008), early family support (Bailey 2008), and appropriate special ed
ucation to optimize critical developmental processes during preschool
and beyond.
Generally, these interventions do not require medication treatments
during the first few years. However, some children with ASD in pre
school years or beyond demonstrate significant problems with inatten
tion, hyperactivity, and impulsive behaviors that are characteristic of
ADHD and that present safety risks or significantly impair their ability
to participate adequately in intervention programs. There are no medi
cations specifically targeted for ASD, but some of these children may
benefit from a cautious trial of medication, although many have a very
sensitive body chemistry and are likely to have more problems with
side effects than most other children of similar age. An excellent guide
for parents on the medical aspects of ASD and AS is Dr. Edward Aull’s
book The Parent’s Guide to the Medical World of Autism: A Physician Ex
plains Diagnosis, Medications & Treatments (Aull 2013).
Individuals with ADHD and AS, unlike most others on the autism
spectrum, usually have language skills that are acquired on time and of
ten developed precociously, although they may speak in a pedantic
manner, and typically demonstrate some degree of interest in social in
teraction. Their social impairments usually do not become fully appar
ent until late preschool years, often becoming much more problematic
during middle childhood and adolescence. They also tend to have at
least average, and often above-average, IQ and narrow, factually ori
ented but circumscribed, areas of interest that tend to interfere with
their learning and with their being able to sustain reciprocal conversa
tion (Volkmar et al. 2014).
Often persons whose ADHD is combined with AS are brought for
treatment during elementary, middle, or high school because of inatten
tion problems and/or problems with social interaction with peers; often
the social problems include persistent difficulties with being bullied. For
example, a 13-year-old boy was brought by his mother for evaluation:
Case Example: A 13-year-old without
developed social skills
Fred was in eighth grade and was in special education classes; he had
been diagnosed with ADHD in fourth grade. He had been prescribed
two different ADHD medications but in each instance had to stop the
medication because of adverse effects, primarily increased anxiety. At
the time of initial evaluation, he was taking 50 mg of sertraline but had
become increasingly resistant to doing schoolwork, often sitting in
classes with his head on his desk, refusing to do classwork or home
work, and missing many days of school with complaints such as stom
achache and headache. At home, he spent most of his time in his room
playing video games. When I asked him to describe himself, he said, “I
hate school, and I have no real friends.” His major complaint was that he
hated being in special education classes: “The teachers keep telling me
that I’m very smart, but they treat me like a fourth grader. I’m not going
to do what they tell me until they start treating me a lot better.”
In our psychotherapy sessions, Fred initially tried to press his argu
ment that his teachers needed to change their behavior before he would
change his. After a few sessions, he responded to my confronting him with
how he would need to change his oppositional behavior at school before
anyone would change anything else for him. I administered an IQ test, and
Fred scored in the superior range. Seeing those results, he said, “OK, I
know I’m smart, but I really am broken.” We then began to talk about how
he would soon be starting high school, where he could be placed in main
stream classes if he could show that he would do his job as a student for the
remaining months of the school year. I also told him that if he wanted to
improve his interactions with classmates, he would need to use his strong
intellect to learn skills for dealing with adults and other kids, skills that
most kids pick up intuitively. Low doses of stimulant medication were pre
scribed for Fred’s ADHD, which he was able to tolerate as the dosage was
very gradually increased. Over the final quarter of the semester, his behav
ior and work output at school improved markedly, and he was able to start
ninth grade in mainstream classes. This combination of having his strong
abilities confirmed while addressing his weaknesses in social skills, com
bined with gradual introduction of ADHD medication, helped to motivate
Fred to make the necessary changes to achieve his goal.
Sometimes the difficulties of someone with ADHD and AS do not

become apparent until the move away from home to college. This is il
lustrated in the vignette about Alan in Chapter 9 (“Emotional Dynamics

in Individuals, Couples, and Families Coping With ADHD”). Addi
tional educational and social support interventions for individuals with
autism as they approach adulthood are provided by Wehman et al.
(2009).
These examples illustrate just a few of the many ways in which in
dividuals whose ADHD is accompanied by AS need assistance. Many
are able to become quite successful if they receive adequate help and
support not only for their ADHD-related impairments but also for their
impaired social skills and for their anxiety, which often involves social
anxiety with chronic avoidance of situations they fear. Medication may
play a helpful role in these difficulties, but it needs to be very cautiously
utilized, starting with minimal dosing and slow increases in dosage, be
cause of these individuals’ often very sensitive body chemistry.
Summary
For the many individuals whose ADHD is complicated by various other
learning, psychiatric, or medical problems, it is very important for the
clinician to adapt treatment plans for the specific needs of the patient.
This is crucial not only for those who fully meet diagnostic criteria for
another disorder but also for patients who are affected by additional
symptoms, even if those symptoms do not fully meet official diagnostic
criteria.
The discussions in this chapter provide some brief guidance for cli
nicians who are treating children or adults whose ADHD is complicated
by additional difficulties. More detailed guidance for such complicated
situations is included in ADHD Comorbidities: Handbook for ADHD Com
plications in Children and Adults (Brown 2009). That edited volume offers,
for example, full chapters on ADHD with anxiety disorders, mood dis
orders, sleep disorders, substance use disorders, oppositional and ag
gressive disorders, and learning disorders in multiple age groups, each
chapter written by experts who are specialists in that field.
This chapter moves beyond the information in Chapter 7 about var
ious co-occurring disorders. It provides information about how ADHD
assessment and treatment may need to be adapted for patients who also
suffer from anxiety, depression, specific learning problems, emotional
regulation and mood problems, sleep and arousal problems, opposi
tionality and/or aggression, obsessional and/or compulsive problems,
substance use problems, Asperger’s syndrome and other autism spec
trum difficulties, or any combination of these.
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Index
Page numbers printed in boldface type refer to tables or figures.
AA (Alcoholics Anonymous), 252

ADHD Comorbidities: Handbook for
Academic skills, 14, 89, 200. See also

ADHD Complications in Children
Education and schooling; Learn and Adults, 256
ing disorders
The ADHD Explosion, xxvi–xxvii
of adolescents, 51
The ADHD Guide to Career Success:
of elementary school children, 49,

Harness Your Strengths, Manage
50
Your Challenges, 221
specific learning disorder and,

ADHD: What Everyone Needs to Know,
104, 238
224
Accommodations and legal protec Adolescents, xvi, xx, 3, 200, 206
tions
adaptive skills usually expected
in college and postgraduate set of, 50–53, 60
tings, 219–221
ADHD medications for, 201
determining eligibility for, 144, 147

α2-adrenergic agonists, 175
in elementary and secondary

atomoxetine, 174
schools, 58, 209–210, 215–218

cardiovascular effects of,
in employment settings, 221

199
in private or religious schools, 218

growth effects of, 199
ACT (American College Testing)

menstrual cycle and response
exam, 133, 217, 219

to, 37
Activities of daily life, xviii, xix, xxii,

stimulants, 185, 192, 197, 198
3, 7, 78, 173–174
attachment figures of, 68
Activity level, 22. See also Hyperac autism spectrum disorder in, 124,
tivity
254–255
ADD Coach Academy, 227

brain maturation in, xx, 31–32, 46,
The ADD Effect on Marriage: Under 60, 82
stand and Rebuild Your Relation imaging studies of, 83
ship in Six Steps, 226

case examples of
ADDA (Attention Deficit Disorder

12-year-old rejected by class
Association), 141
mates, 156–157
Adderall; Adderall XR (amphet 12-year-old whose divorced
amine), 174, 175, 185

parents disagree about his
Addiction. See Substance use disor treatment, 157–158
ders
13-year-old who cuts herself
ADDitude magazine, 224

when she gets disappoint
AD/HD and the College Student: The
ing grades, 158–160
Everything Guide to Your Most

13-year-old without developed
Urgent Questions, 220

social skills, 255
279
Adolescents, case examples of (con ADHD medications and risk

tinued) of, xix, 1–2, 199
14-year-old who struggles with evaluation for, 135, 250–251
homework after losing supportive relationships of, 95–96
mother’s help, 161–162 α2-Adrenergic agonists, 174, 180, 181
15-year-old whose parents bat combined with stimulants, 181,
tle over his punishment, 241, 246
160–161 Adult ADHD-Focused Couple Therapy:
clinical interview of, 132–136 Clinical Interventions, 226
conduct disorder in, 115–116, 246 The Adult ADHD Tool Kit: Using CBT
depressive disorders in, 110, 112 to Facilitate Coping Inside and
antidepressants for, 242 Out, 225
effect of family adversities on, 92, Adults with ADHD, xvii, 2, 223–224.
95 See also Young adults
frequency of comorbid disorders accommodations and legal pro
in, 101, 126, 137 tections in employment set
intelligence tests for, 238 tings, 221
learning disorders in, 101, 126, adaptive skills usually expected
137 of adults, 56–60
disorder of written expression, age at symptom onset, xvii, 31–33
105 case examples of
reading test for, 147 divorced woman immobilized
memory tests for, 139–140 by undiagnosed ADHD
need for extra supports, 90 and shame, 165–167
nonpharmacological treatment of, married couple on the brink of
211 divorce because of the
cognitive-behavioral therapy, husband’s untreated
224, 236–237 ADHD, 167–169
guidance for parents, 206 characteristics of, 35
obsessive-compulsive disorder in, comorbid learning or psychiatric
117 problems of, xix
onset of ADHD symptoms in, DSM-5 diagnostic criteria for, xxi,
xvii, xxi, 31, 33, 34, 46, 80 xxiii, 35
oppositional defiant disorder in, effects of bodily changes of aging,
115–116, 246 92–94
persistence or remission of environmental stressors and, 44
ADHD symptoms in, 5, 22, executive function impairments
30, 34, 35, 95 of, xx
risks associated with ADHD in, gender distribution of, xvi, 37
200 medical problems of, 223
sexual behavior of, 52 medication treatment of, 171–201
sleep and arousal problems of, older adults, 93–94
184, 242–245 effectiveness of medications
substance use disorders in, 52, for, 182–183
122–124, 250 outcome studies of, 59–60
Index 281
psychotherapy for while taking ADHD medications,

cognitive-behavioral therapy, 193–194, 249, 253
224–225 Alcoholics Anonymous (AA), 252
couple therapy, 225–226 Alertness. See Sleep and alertness
supportive psychotherapy, Alfano CA, 236
221–224 Alternative treatments, 227–229, 230
resources for, 223–224

Alzheimer’s disease, 13, 93
Adzenys XR (amphetamine), 176

American College Testing (ACT)
Age at onset of ADHD symptoms,

exam, 133, 217, 219
xvii, 5, 12, 30–34, 46

Americans with Disabilities Act of
Age-related executive functioning

1990, 144, 221
impairments, 45–60
Amphetamines, 87, 174, 181, 189,
adolescents, 50–53
198, 246
adults, 56–60
dosing of, 175–176, 183
elementary school children, 33,

mechanism of action of, 87, 88,
47, 49–50, 80
173
preschool children, 48–49, 60

Amygdala, 39, 63–64, 83, 113, 173
young adults, 53–55

Anger, 18–19, 49, 64, 70, 133, 151,
Aggressive behavior, 67, 240, 256

152, 154, 155, 156
in bipolar disorder, 114

of adults with ADHD, 112, 168,
in conduct disorder, 116, 246

221
medications for, 246–247

aggression and, 153–154
α2-adrenergic agonists, 174,

in bipolar disorder, 114, 115, 242
181, 246
child who has outbursts of rage
stimulants, 241, 246

followed by guilt, 153–155
of preschool children, 12
in oppositional defiant disorder,
treatment of ADHD with,
115, 245
245–247
of parents, 70, 154, 161
Aging
of preschoolers, 49
ADHD in menopausal women,

stimulant dose–related, 182
xx, 37–38, 94, 166–167

of teachers, 43
bodily changes of, 92–94

temperament and, 38
dopamine brain activity and, 93

Antianxiety medications, 234, 235,
executive function impairments

236
and, xx
Antidepressants, 167, 192, 207, 237
Agoraphobia, 109
mania induced by, 242
Alcohol use, xxii, 29, 249–252

for sleep problems, 245
by adolescents, 52
Antipsychotics, atypical, 242, 246
avoidance of, 47, 52

Anxiety and anxiety disorders, xix,
elevated risk for, 91, 123

xxii, 6, 107–110
history taking for, 131, 134, 135

ADHD and, 107–109
maternal abuse during preg treatment of, 234–237
nancy, 42
elevated risk for, 102, 107, 137
recovery from addiction to, 97

as self-medication, 91–92
and, 109–110
Anxiety and anxiety disorders, execu resources for, 146–148
tive impairments and (continued)

books, 146
attentional bias, 109–110

broader screens for behavioral
working memory, 110, 112

and emotional function
generalized anxiety disorder, 109
ing, 147
panic disorder, 108–109, 134, 234,

information from teachers,
235
146, 209, 213–214
phobic fears, 107–108

psychoeducational testing
social anxiety, 108, 125, 163, 236,

reports, 146–147
256
report cards or school or col
Apathy, 51
lege transcripts, 146, 214
Apgar scores, 42
scale for autism spectrum
Appetite, 131, 136

screening, 147–148
medication effects on, 51, 183,

screening for co-occurring disor
187, 189, 198
ders, 136–138
Aptensio XR (methylphenidate), 177

Assumptions about ADHD, xv–xxii
AS (Asperger syndrome), 124–127,

Atomoxetine, 174, 180, 181, 189, 241
253–255, 256
Attachment theory, 68
ASD. See Autism spectrum disorder

Attention Deficit Disorder: The Unfo
Asperger syndrome (AS), 124–127,
cused Mind in Children and
253–255, 256
Adults, 224
Assessment for ADHD, xix, 129–149

Attention Deficit Disorder Associa
brief measures of working mem tion (ADDA), 141
ory, 139–140
Attention magazine, 224
clinical assessment, 131–132 Attention networks, 102–103
objectives of, 131–132 Attentional bias, 109–110
with patient and collaterals, Attentional problems, xvi, 3, 34. See
132
also Focusing attention
time required for, 132

in elderly persons, 93
DSM-5 diagnostic criteria, 138–139

functional connectedness in brain
elements of clinical interview,

and, 85
132–136 persistence of, 35
explanation of ADHD with que temperament and, 38
ries, 141–144 Auditory verbal memory tasks,

instruments less helpful for, 139–140
148–149
Aull E, 254
lack of single test for, 130, 144, 149

Autism spectrum disorder (ASD), 6,
modifications for younger chil 124–127

dren, 144–146 ADHD and, 124–125
neuropsychological testing, xix,
genetic studies of, 124–125
129–130, 148–149, 239
treatment of, 253–256
psychoeducational testing, 144,
Asperger syndrome, 124–127,
146–147, 215, 238–239

253–255, 256
rating scales, xix, 112, 130, 132,

early diagnosis and treatment of,
138, 139, 144, 147, 214

254
Index 283
elevated risk for, 102


and, 113–114
and, 125–127
suicide and, 113, 114, 242
resource for parents about, 254

A Bird’s-Eye View of Life with ADHD
screening instrument for, 147–148

and EFD...Ten Years Later: Advice
“Automatic system” of the mind,

From Young Survivors, 3rd Edi
8–10, 65
tion, 220
Axons, 86
Body dysmorphic disorder, 119
Bowlby J, 68
Baird AL, 244

Brain
Barkley RA, 111, 149, 208, 218

aging-related changes in, 93
Baron-Cohen S, 125
amygdala, 39, 63–64, 83, 113, 173
BASC-3 (Behavioral Assessment for

attention networks of, 102–103
Children—Third Edition), 147,

“automatic system” of, 8–10, 65
214
default mode network of, 85–86,
Behavior problems, xv, xvi, 3, 4, 11,

88
29–30, 129, 141

electrochemical communication
conduct disorder and, 116, 246

in, 9, 86–88, 142–143, 172–173
oppositional defiant disorder

situational specificity of moti
and, 115–116, 245
vation and, 74–76
resolving parental differences of emotions prioritizing motiva

opinion about management tions in, 63
of, 207–208 explaining functions to patient/
Behavior Rating Inventory of Execu family, 142–143
tive Function, 214

gray matter of, 81–83, 172
Behavioral Assessment for Chil similarities and differences
dren—Third Edition (BASC-3),

between Google searches
147, 214
and, 62–63, 173
Behavioral interventions, 228, 229

size and weight of, 172
for autism spectrum disorder, 254

stimulant effects on functioning
parent training, 230

of, 87–88
in schools, 216
System 1 and System 2 of, 8–9
for sleep problems, 245

white matter of, 83–84, 172
for substance use disorders,

aging-related decreases in, 93
252–253
working memory as a network
Beidel DC, 236

rather than a structure in,
Benton CM, 208

71–72
Benzodiazepines, 234, 235

Brain development
Bipolar disorders, 113–115. See also

in autism spectrum disorder, 83
Mania
cortical thickening, 81–83
ADHD and, 113–114

delays and catching up, xviii, 82,
treatment of, 242

95, 212
bipolar I and bipolar II disorders,

differences in persons with
114
ADHD, xxvi, 3, 4–5, 81–88, 99
elevated risk for, 113

brain structure, 81–84
Brain development, differences in

CHADD. See Children and Adults
persons with ADHD (continued)
with Attention-Deficit/Hyper
electrochemical communica activity Disorder
tion, 86–88
Child Behavioral Checklist (CBCL),
functional connectedness, 71,

147
84–86
Children and Adults with Attention
environmental influences on, 99
Deficit/Hyperactivity Disorder
genes and, 81
(CHADD), 141, 223
imaging studies of, 4–5, 82, 84

Parent to Parent Program, 230
need for medications related to,

Children’s Memory Scale, 140
195
Circles inside squares graphic orga
in persons with remitting vs. per nizer, 144, 205
sisting impairments, xvii,

Clinicians
36–37, 82
empathy of, xxvi, 153, 211, 252
supporting of executive functions

lack of current scientific under
by, xviii, xx, 3, 13, 31–32,
standing of ADHD, xxii
45–46
training for ADHD diagnosis, xx,
vs. typical development, xx, 46

xxvii–xxviii
Brown ADD Rating Scales, 112, 138,

Clomipramine, 248
214
Clonidine, 174, 180, 181, 245
Brown Executive Function/Atten Co-occurring disorders, xix, 5–6,
tion Rating Scales, 138, 139

91–92, 101–127
Brown TE, 111, 149, 220, 224, 244
anxiety disorders, 107–110, 234–237
Web site, 144, 205, 210, 216
Asperger syndrome/autism spec
Bulimia, 137
trum disorder, 124–126,
Bullying, 157, 212, 255
253–256
Burgess P, 149
bipolar disorders, 113–115
Buzzed: The Straight Facts About the
depressive disorders, 110–113,
Most Used and Abused Drugs
237
From Alcohol to Ecstasy, 251

elevated risk for, 91, 101–102, 102,
103, 137
Cardiovascular effects of ADHD emotional regulation and mood
medications, 198–199 problems, 240–242
Carlson GA, 242

learning disorders, 103–107,
Carroll KM, 252

238–240
CBCL (Child Behavioral Checklist),

obsessive-compulsive and related
147
disorders, 117–121, 247–249
CBT. See Cognitive-behavioral ther oppositionality and aggression,
apy 115–117, 245–247

CD. See Conduct disorder screening for, 131, 136–138
Centers for Disease Control and Pre sleep and arousal problems,
vention, 224
242–245
Central mystery of ADHD, 6–10, 61,
substance use disorders, xix, xxi,
78, 91, 106. See also Situational

xxii, 6, 29, 91–92, 121–124,
specificity of motivation
249–253
Index 285
supportive psychotherapy for

Conduct disorder (CD), 115–117
adults with, 222–223

ADHD and, 115, 116, 246
treatment of ADHD in patients

with, 233–256 elevated risk for, 102, 137
Coach Approach for Organizers, 227

Coaching for ADHD, 98, 163, 203,

and, 116–117
227, 231
prevalence of, 116
academic, 220
Conners’ ADHD Rating Scales, 138,
training of coaches, 227

214
Cocaine use, 91, 123, 249, 250

for Adults, 112
Coghill D, 188
Conners’ Comprehensive Behavior
Cogmed Working Memory Training

Rating Scales, 147
program, 229
Conners’ CPT-II, 148
Cognitive abilities, xviii, 5, 7, 39–41

Continuous Performance Test (CPT),
autism spectrum disorder and,

148
254, 255
Cortese S, 244
IQ tests of, 146–147, 238–239

Cortical thickening, 81–83. See also
substance use disorders and, 251

Brain development
Cognitive-behavioral therapy (CBT)

Costello E, 146
for ADHD, 163, 224–225, 231

Could It Be Adult ADHD? A Clini
with anxiety, 234, 236–237
cian’s Guide to Recognition,
with conduct disorder, 246

Assessment, and Treatment, 146
with obsessive-compulsive and

Couple therapy for adults,
related disorders, 249

225–226
resources for, 225

CPT (Continuous Performance Test),
Cognitive-Behavioral Therapy for Adult

148
ADHD: An Integrative Psychoso “Crashing” when ADHD medication
cial and Medical Approach, 2nd

is wearing off, 190, 241
Edition, 225
Creativity, xxiv, 39
Cognitive-Behavioral Therapy for Adult

Criticism of person with ADHD,
ADHD: Targeting Executive Dys 90–91, 166, 212
function, 225
child’s complaints about,
Cognitive training, 228, 230

152–153
Collaborative Multisite Multimodal

by parents, 42–43
Treatment Study of Children

peer rejection and, 157
With Attention-Deficit/Hyper vs. praise, 153
activity Disorder, 101, 102

reactions to, 50, 112
Compensatory strategies, 98
self-criticism, 166, 167
Comprehensive Executive Function

by teachers, 214
Inventory, 214
Cultural knowledge, 51
Computer training programs,
228–229, 230
Damasio A, 65–66, 68
Computerized tests for ADHD, 148

Dangerous behavior and risks
Concerta (methylphenidate), 174,

of adolescents, 52
178, 185, 193

of preschoolers, 48
Dating relationships, 52, 55, 57, 169, substance use disorders and, 121
223. See also Partner relation suicide and, 110, 111, 237
ships treatment-resistant, 188
22-year-old in conflict with his working memory problems and,
girlfriend and her reaction to 112–113
his ADHD, 164–165 Developmental delay, 13, 25, 46
couple therapy, 225–226 Dexedrine; Dexedrine Spansule
Dawson P, 208 (dextroamphetamine), 87, 175,
Daytrana (methylphenidate), 174, 176
178 Diagnosis of ADHD, xvi, xix
Deadlines and time management, 6, arguments about overdiagnosis,
16, 23, 34, 40, 47, 66, 73–74, 120 xxvi
Death, xxii, 59 assessment for, xix, 129–149
Delay discounting, 74 inadequacy of DSM-5 diagnostic
Dementia, xx, 13, 93, 94 criteria, xxi
Dendrites, 86 increased impairment due to
Depressive disorders, xix, xxii, 4, 27, inadequacy of, 94
29, 59, 91, 94, 98, 110–113, 126, professional training for, xx, xxvii
151, 165, 166, 167, 188, 233, 234, related to severity of impairments,
237, 256 4
ADHD and, 110–111, 137
rising rates of, xxvi–xxvii, 2–3
genetic studies of, 113
Diagnostic and Statistical Manual of
treatment of, 237
Mental Disorders (previous edi
antidepressants for, 242 tions)
asking patient about, 132, 134 ADHD relation to bipolar disor
bipolar disorder and, 114 der, 113
college support services for, 220 age at onset criterion for ADHD, 30
counseling/psychotherapy for, introduction of term “attention
211, 222 deficit,” 29–30
elevated risk for, 102, 110, 137 persistence of ADHD symptoms
with emotional dysregulation, meeting DSM-IV diagnostic
111–112, 240, 242 criteria, 35
rebound moodiness when Diagnostic and Statistical Manual of
medication is wearing off, Mental Disorders, Fifth Edition
241 (DSM-5)
executive function impairments ADHD diagnostic criteria in, xxi,
and, 111–113 xxviii
major depressive disorder, 111 for adults, xxi, xxiii
obsessive-compulsive disorder age at onset criterion, 31, 46
and, 248 hyperactivity criterion, xvi,
oppositional defiant disorder xxiii, 4, 30
and, 116 lack of emotional problems cri
of parents, 42, 154 terion, 187–188
persistent depressive disorder limitations and suggestions for
(dysthymia), 110–111, 237 improvement of, xxviii
Index 287
noninclusion of executive
effects of ADHD medications on,
function impairments, xxi,

75, 88, 174, 197
xxiii
estrogen-modulated release of,
for patient assessment, 138–139

37, 94, 167
presenting summary score to

role in situational specificity of
patient/parent, 144
motivation, 75, 78
worldwide applicability of, xxi

Dressing oneself, 13, 46, 48
ADHD term in, xxiii

Driven to Distraction: Recognizing and
autism spectrum disorders in,

Coping With Attention-Deficit
125, 126, 253

Disorder, 224
conduct disorder in, 116

Driving, 3, 13, 20, 24, 28, 117, 118–119,
disruptive mood regulation disor 130, 200
der in, 114

by adolescents, 52
obsessive-compulsive disorder in,

brain maturation necessary for, 32
247
focusing attention for, xvi, 16–17
oppositional defiant disorder in,

too fast, 22–23
115
Drug addiction. See Substance use
specific learning disorder in,
disorders
103–104
DSM. See Diagnostic and Statistical
Dietary treatments, 228, 230
Manual of Mental Disorders
Diffusion tensor imaging (DTI), 84
DTI (diffusion tensor imaging), 84
Digit span test, 139, 140, 144

Dyanavel (amphetamine), 176
Diphenhydramine, 245
Dyscalculia (mathematics disorder),
Disappointment, 18, 43, 49, 53, 70, 76,

104, 107, 215, 238, 239. See also
91, 151, 158, 159, 161

Math tasks and skills
Disorder of written expression, 104,

Dyslexia (reading disorder), xix, 104,
105–107, 215, 238, 239. See also

107. See also Reading tasks and
Writing tasks and skills
skills
Disruptive mood regulation disor Dysthymia (persistent depressive
der, 114. See also Emotional dys disorder), 110–111, 237
regulation
Distractibility, 17, 40, 41, 126, 130. See
Eating and nutrition, 47, 77, 131

ADHD medications and, 183, 187,
driving and, 52
189
of elementary school children, 49

of adolescents, 51, 156
imaging studies of, 86, 88, 196

anxiety and, 235
depression and, 111
stimulant effects on, 88

dietary treatments, 228, 230
Divorce, 35, 59, 60, 92, 157–158, 159,

Edge Foundation, 227
165, 167
Education about ADHD for patient/
Dodge K, 63
family, 132, 141–144, 203–206
Dopamine, in networks that manage

Education and schooling, xxi, xxii, 2,
executive functions, 75, 167, 172

3, 7, 36. See also Homework;
age-related decline in brain activ Teachers
ity of, 93
additional supports for, 229–230
Education and schooling (continued)

repeated failures in, 29
age-related impairments related

school supports and accommoda
to, 47
tions for students with
assessment of current school situ ADHD, 58, 144, 209–210,
ation, 133
215–218
case examples of
skills usually expected of adoles
7-year-old who feels picked on
cents, 51
by adults, 152–153
skills usually expected of elemen
11-year-old who “goes on
tary school children, 49–50
strike” when asked to

special education services, 58,
write, 155–156
215–216, 217, 254, 255
12-year-old rejected by class standardized tests, 1, 122, 133,
mates, 156–157
213, 217, 219, 239
13-year-old who cuts herself

as stress or support for child with
when she gets disappoint ADHD, 43
ing grades, 158–160

transition from elementary school
14-year-old who struggles with

to middle school, 161
homework after losing

transition from high school to col
mother’s help, 161–162
lege, 90, 220
18-year-old who fails in first

transition from middle school to
semester of college,
high school, 161–162
162–164
transition to employment from,
collaboration with elementary

54
and secondary schools,

usefulness of report cards or
212–219, 231
school or college transcripts,
completion in young adulthood,

146, 214
53–54
what to tell the school about
failure to graduate from high

child’s ADHD, 209–210
school, 35, 51, 122, 158, 200

EFDD (executive function deficit dis
impact of substance use disorders
order), xxiii, 11
on, 122–123
Electrochemical communication in
individualized education plan,

brain, 9, 86–88, 172–173
217–218, 219
explaining to patient/family,
intelligence and, 39–41

142–143
lack of motivation to do school situational specificity of motiva

work, 36, 40
tion and, 74–76
memory problems for test taking,

stimulant effects on, 87–88, 172,
21–22
173
obtaining a college degree, 35,

Elementary school children, 33, 47,
53–54
80, 159
parental support for, 43

plan for after high school, 52–53,

of, 49–50, 89
200
case examples of
psychoeducational testing, 144,

7-year-old who feels picked on
146–147, 215, 238–239

by adults, 152–153
Index 289
8-year-old with outbursts of 22-year-old in conflict with his

rage followed by guilt, girlfriend and her reaction to
153–155 his ADHD, 164–165
collaboration with school, 212–219,
divorced woman immobilized by
231
undiagnosed ADHD and
with comorbid ADHD and
shame, 165–167
Asperger syndrome, 255
married couple on the brink of
explanation of ADHD for, 141
divorce because of the hus
guidebook for teachers of, 218
band’s untreated ADHD,
risks associated with ADHD in,
167–169
200
Emotional dysregulation, xv, xviii, 4,
teacher evaluations of, 146, 209,

5, 15, 18–20, 24, 44, 256. See also
213
Aggressive behavior; Irritability
transition to middle school, 161

vs. adaptive emotional regula
Ellison K, 224
tion, 114
Emotion(s), 151–152
ADHD medications and, 240–241
as basis of motivation and self bipolar disorder and, 242
regulation, xviii, 5
conduct disorder and, 116
unconscious prioritizing by,

definition of, 238
64–66, 72
depression and, 111–112, 240, 241,
working memory and, 69–70

242
The Emotional Brain, 63

disruptive mood regulation disor
Emotional dynamics, case examples der, 114
of, 151–169 items on ADHD rating scales for,
7-year-old who feels picked on by 112
adults, 152–153 mania and, 115
8-year-old with outbursts of rage oppositional defiant disorder
followed by guilt, 153–155 and, 116
11-year-old who “goes on strike” of preschoolers, 48–49
when asked to write, 155–156 prevalence of, 240
12-year-old rejected by class stimulant effects on, 188, 241–242
mates, 156–157 treatment of ADHD with, 240–242
12-year-old whose divorced par Empathy
ents disagree about his treat of clinician, xxvi, 153, 211, 252
ment, 157–158 conduct disorder and deficiency
13-year-old who cuts herself of, 246
when she gets disappointing in couple therapy, 226
grades, 158–160 of parent, 210
14-year-old who struggles with of teachers, 214
homework after losing Employment

mother’s help, 161–162 accommodations and legal pro
15-year-old whose parents battle tections for persons with
over his punishment, 160–161 ADHD in work settings, 221
18-year-old who fails in first assessment of current work situa

semester of college, 162–164 tion, 133
Employment (continued)
activation: organizing, prioritiz
difficulties with, xxi, xxii, xxiii, 2,
ing, and activating to work,
3, 6, 29, 35, 36
14–15, 45
education/training for, 53
age at onset of, xvii, 5, 12, 30–34, 46
finding success in work that fits

age-related, 45–60
interests and skills, 96–97

adolescents, 50–53
job loss/unemployment, 44, 54,

adults, 56–60
59, 60, 133

elementary school children, 33,
sustaining of, 56, 200

47, 49–50, 80
transition from school to, 54

preschool children, 48–49, 60
Environmental factors, 41–44

young adults, 53–55
prenatal exposures and preg aging and, xx
nancy complications, 42
anxiety disorders and, 109–110
stresses resulting from, 92

Erhardt D, 145
125–127
Essentials of ADHD Assessment for bipolar disorders and, 113–114
Children and Adolescents, 145
as characteristics rather than
Estrogen level, xx, 37–38, 94, 167
cause of ADHD, 12
Evekeo (amphetamine), 175

compensatory strategies for, 98
Excoriation disorder (skin picking),

computer training programs for,
119, 247
228–229, 230
Executive function(s)
depressive disorders and, 111–113
“automatic system” of the mind,

due to developmental delay, 13, 25
8–10
effort: regulating alertness, sus
brain development supporting,
taining effort, and adjusting
xviii, xx, 3, 13, 31–32, 45–46

processing speed, 17–18, 45
brain networks associated with, 12

emotion: managing frustration
definition of, xv, 13

and modulating emotions,
dopamine and, 75, 167, 172

18–20, 45
dynamic interactions of, 23–24

focus: focusing, sustaining atten
emotions and, 63
tion on tasks, and shifting
intelligence and, 41
attention when needed,
to modulate anxiety, 234–235

16–17, 45
persistence of, xx
gender and, 37
six-factor model of, 14, 15, 24–25,

how ADHD sometimes becomes
45–46 more problematic, 88–94, 99,
tests of, 129–130, 148–149 212
typical (“normal”) development how ADHD sometimes improves,
of, 13–14, 46
95–99, 212
Executive function deficit disorder

vs. lack of willpower, xvii, xxiv, 8,
(EFDD), xxiii, 11
10, 61, 75
Executive function impairments,

marijuana use and, 194
xv–xvi, xvii, 4, 11–25, 15, 169

memory: using working memory
action: monitoring and self and accessing recall, 20–22,
regulating action, 22–23, 45

45
Index 291
in menopausal women, xx, 37–38,

Focusing attention and effort, xv, 4,
94, 166–167
6, 13, 15, 16–17, 24, 25, 45, 61, 79,
noninclusion in ADHD diagnos 126, 130, 214
tic criteria, xxi, xxiii

ability to shift focus, xv, 4, 48, 71,
obsessive-compulsive and related

120, 126, 130, 238
disorders and, 120–121

anxiety and, 109, 235

cognitive ability and, 40–41
and, 116–117
for driving, xvi, 16–17
other learning or psychiatric dis by elementary school children, 49,
orders and, xix

50
severity of, 4, 28–29

emotional dysregulation and, 240
situational specificity of motiva functional connectedness with
tion and, xvii, xxii, xxiv, 6–8,

brain and, 85–86
61, 74–76, 90–91, 106, 149,

mania and, 114
161, 173–174
marijuana effects on, 194

obsessive-compulsive disorder
104–107
and, 120
substance use disorders and,

by preschool children, 48
122–124
situational specificity of, xvii, xxii,
variability of, 5, 7, 27–44

xxiv, 6–8, 61, 74–78, 90–91,
Exercise, 7, 51
106, 149, 161, 173–174
stimulant effects on, 88, 182, 187,
Family, 3. See also Parents of child

190, 192
with ADHD
Fodor J, 41
as collateral information source,

Foreign language learning, 147, 239
132
Freud S, 65
education about ADHD for, 132,

Friendships, xxiv, 29, 38, 40, 41, 131,
141–144, 203–206
169
factors associated with psychiat of adolescents, 50, 52, 160, 243, 255
ric problems in children, of adults, 56–57, 200, 223
42–43 asking patient about, 133
impact of stresses in, 134, 154–155

bipolar disorder and, 114
of origin, 134
death of a friend, 44, 60
Family psychiatric history, 79, 131,

depression and, 98, 111
134, 142, 154, 241

of elementary school children, 50,
FastTrack Coach Academy, 227

200
Financial management, 3, 28, 54

friends as collateral information
expectations of young adults, sources, 132
54–55, 200
peer rejection, 50, 90, 156–157,
Financial stress, 154

212, 255
504 plan, 215–217, 219

as “social capital,” 252
fMRI. See Functional magnetic reso substance use disorders and, 98,
nance imaging
121, 124
Focalin; Focalin XR (dexmethylphe supportive relationships, 95–96,
nidate), 174, 177, 178, 185

212
Friendships (continued)
teacher observations of, 214

in menopausal women, xx,
of young adults, 55, 66, 163, 200,

37–38, 94, 166–167
220
in persistence of impairments, 35
Frustration, xxiv, xxvi, 7, 15, 28, 29,

Generalized anxiety disorder, 109
67, 151, 153

Generic medications, 192–193
about chronic lateness, 243

Genetic factors, xviii, 4, 79–81, 99
of adolescents, 50, 52, 53

affecting brain maturation, 81
of adults with ADHD, 165, 166,

age at symptom onset and, xvii, 80
168–169
environmental factors and, 41–42,
couple therapy for, 225

92
asking patient about, 136

family history and, 79, 131, 134,

154, 241
depression and, 237

heritability, xviii, 4, 58, 79–80, 99,
driving and, 52
142, 210
employment and, 54, 154

linking ADHD and autism spec
impulsive anger due to, 154
trum disorder, 124–125
management of, 18–20, 24, 45, 46

linking ADHD and depression,
113
and, 120
linking ADHD and substance use
of parents, 70, 90, 155, 211

disorders, 121, 124
twin studies, 4, 33, 79–80
stimulant dose–related, 182, 190

GMAT exam, 133, 219

Google searches, similarities and dif
supportive relationships to help
ferences between brain and,
deal with, 43, 96

62–63
of teachers, 43
Graphic organizer, 144, 205
trial of stimulant in person with,

Gray matter of brain, 81–83, 172
241
GRE exam, 133
Functional magnetic resonance

Growth effects of ADHD medica
imaging (fMRI), 130
tions, 158, 198, 199
in autism spectrum disorder,

Growth pattern, 131, 136
125
Guanfacine, 174, 180, 181, 189, 241,
of functional connectedness in
246
brain, 84–86
Guare R, 208
of memory impairments in
Guidance for parents, 206–212
depression, 112–113
of stimulant effects on brain func Hair pulling (trichotillomania), 119,
tioning, 88
247
Fuster J, 64–65, 102–103

Hallowell E, 224, 226
Hallowell SG, 226
Gambling problems, 137

Hammerness PG, 207
Gardner H, 41
Harm reduction approach to sub
Gender differences, 37–38
stance use disorders, 252
in ADHD prevalence, xvi, 2, 37

Harstad E, 249
Index 293
Head injury, 13, 135 IEP (individualized education plan),

Health care and insurance, 58–59, 201 217–218, 219
Health insurance coverage for ADHD Imaging studies, xix, 4–5. See also
assessment and treatment, 99 specific imaging modalities
Health status, xxiii, 29, 134–135 of adults whose ADHD symp
Heritability, xviii, 4, 58, 79–80, 99, toms have remitted or per
142, 210. See also Genetic factors sisted, 37, 82
Heroin use, 1, 249, 250 of aging-related changes in brain,
Hinshaw S, xxvi–xxvii, 2, 224 93
Hoarding disorder, 119, 120–121, in assessment for ADHD, 130
247, 248 of brain changes due to illicit
Homeopathic medicines, 165, 166 drugs, 121
Homework, xxv, 7, 34, 49, 89, 184, of brain effects of ADHD medica
189, 243 tions, 196–197
asking students about, 133 of brain structure and maturation,
criticism/punishment about, 90 4–5, 82–84
lack of motivation to complete, of functional connectedness in
36, 40 brain, 71, 84–86
management by adolescents, 51, Improvement of ADHD impair
80, 159, 160, 186, 255 ments, factors associated with,
case example of 14-year-old 95–99, 212
who struggles with home adequate assessment and treat
work after losing mother’s ment, 98–99
help, 161–162 beneficial partner relationship, 97,
management by school-aged chil 98
dren, 50, 200 brain development that catches
parent support for, 43, 47, 161, up, 95
162, 186, 213 compensatory strategies, 98
Hopelessness, xxv–xxvi, 51, 90, 111, recovery from substance use dis
151, 155, 166 order, 97–98
Hospitalization, psychiatric, 114, 237 success in work that fits interests
How to Reach and Teach Children With and skills, 96–97
ADD/ADHD: Practical Tech supportive relationships, 95–96
niques, Strategies, and Interven Impulsivity, xvi, xxiii, 4, 18, 22
tions, 218 age at onset of, 31
Human Genome Study, 124 angry outbursts and, 154
Hyperactivity, xv, xvi, 4, 22, 29–30 assessment of, 129, 139
autism spectrum disorder and, 254 autism spectrum disorders and,
remission of, 34, 35, 95 126, 254
temperament and, 38 bipolar disorders and, 114, 115
Hypomania, 114 conduct disorder and, 116
couple therapy for adults with,
IDEA (Individuals with Disabilities 225, 226
Education Improvement Act of in decision making, 66, 69
2004), 144, 215, 218 differences in intensity of, 29–30, 44
Impulsivity (continued)
rebound moodiness and, 241
driving and, 28, 52

stimulants, 241
financial management and, 28, 54

115, 245, 246
and, 120

stimulant dose–related, 182, 188,
and, 116
190, 191, 192
outgrowing symptoms of, 95

in substance use disorders, 121
in preschool children, 12, 48

temperament and, 38
in sexual relationships, 52
Is It You, Me, or Adult A.D.D.? Stop
stimulant medications for allevia ping the Roller Coaster When
tion of, 197, 246

Someone Your Love Has Attention

Deficit Disorder, 226
temperament and, 38
IVA-2 (Integrated Visual and Audi
Individualized education plan (IEP),
tory 2), 148
217–218, 219
Individuals with Disabilities Educa Joshi G, 242
tion Act Amendments of 2006

JST Coaching & Training, 227
(P.L. 94-142), 215
Individuals with Disabilities Educa Kagan J, 38
tion Improvement Act of 2004

Kahneman D, 8, 9
(IDEA) (P.L. 108-446), 144, 215,

Kapvay (clonidine), 174, 180, 181, 245
218
Kessler RC, 137
Insomnia. See Sleep and arousal

Khan Academy, 229
problems
Klass P, 146
Integrated Visual and Auditory 2
(IVA-2), 148
Larson K, 137
Intelligence (IQ), xviii, 5, 7, 39–41

Lateness, 6, 17, 29, 77, 136, 165, 166,

244
254, 255
Latham PH, 221

Latham PS, 221
tests of, 146–147, 238–239

Law boards, 219
Intermittent explosive disorder, 137

Laziness, xxiv, 43, 90, 160, 209
Intuniv (guanfacine), 174, 180, 181,

Learning Disabilities/ADHD and the
189, 241, 246

Law in Higher Education and
IQ. See Intelligence

Employment, 221
Irritability, 240
Learning disorders, xxii, xxiii, 3, 6,
on awakening, 184
102, 103–107, 200. See also Math
in bipolar disorder, 113, 114, 115

tasks and skills; Reading tasks
in generalized anxiety disorder,

and skills; Writing tasks and
109
skills
history taking for, 134, 136

ADHD and, 103–104
medications for
α2-adrenergic agonists, 181

definition of specific learning dis
antidepressants, 242
order, 103–104
Index 295
executive function impairments Marijuana use, xxii, 91, 97, 123, 249,
and, 104–107 250
psychoeducational testing for, ADHD medications and, 192, 195,
144, 146–147, 215, 238–239 253
school accommodations and legal

assessment for, 131, 135, 250
protections for students with,

215–218, 240
and, 194
screening for, 131, 137

Marriage, 55, 56, 57, 60, 166, 226. See
working memory problems and, also Partner relationships
21, 104–105, 156, 238, 239

case example of married couple
LeDoux J, 63, 65, 68
on the brink of divorce
Legislation
because of the husband’s
Americans with Disabilities Act
untreated ADHD, 167–169
of 1990, 144, 221
couple therapy, 225–226
Individuals with Disabilities Edu Married to Distraction: Restoring Inti
cation Act Amendments of
macy and Strengthening Your
2006, 215
Marriage in an Age of Interrup
Individuals with Disabilities Edu tion, 226
cation Improvement Act of

Math tasks and skills, 36, 41, 51, 96,
2004, 144, 215, 218

104, 105–106, 134, 135, 145, 155,
Section 504 of the Rehabilitation

156, 200
Act of 1973, 144, 215, 218,

extended time for taking tests, 216
221
mathematics disorder (dyscalcu
Leisure-time activities, 133
lia), 104, 107, 215
Levy S, 249
treatment of ADHD with, 238,
Lezak M, 13
239
Lithium, 246
MCAT exam, 133, 219
Littman EB, 208

McMullen WJ, 244
Living arrangements, 134

Media coverage of ADHD, xxii, xxvi,
establishment of a home, 57
1–2, 10
Logical Memory test, 140

Medications for ADHD, 171–201
Long-term outcome studies, xxi

adverse effects and risks of,
Love relationships, 35
197–200
Low birth weight, 42

alarmist media warnings about
LSAT exam, 133, 219, 220

increasing use of, 1–2
alcohol use and, 193–194, 253
Magnetic resonance imaging (MRI),

to alleviate aging-related execu
8, 81, 83. See also Functional
tive function impairments, xx
magnetic resonance imaging

assessing impact on anxiety and
Managing ADHD in School: The Best

mood, 187–189
Evidence-Based Methods for Teach beneficial effects of, xviii, 3, 6, 10,
ers, 218
87–88, 143, 171, 191, 201
Mania, 114, 115, 242. See also Bipolar

cardiovascular effects of, 198–199
disorders
“crashing” when medication is
antidepressant-induced, 242
wearing off, 190, 241
Medications for ADHD (continued) in patients with tics, 174, 181
dosing of, 181–182, 207

preparations of, 174
for older adults, 183

α2-adrenergic agonists, 174,
rebound and, 190–191, 241

180, 181
signs dose is too high, 190

amphetamines, 174, 175–176
duration of treatment with,

atomoxetine, 174, 180, 181
195–196
methylphenidate, 174, 176–179
effectiveness of, 191, 207

resolving parental differences of
evidence for, 196–197
opinion about, 43, 157–158,
factors associated with, 181–182
207–208
for generic formulations,
safety of, xix, xxii, xxvi, 206–207
192–193 substance use disorder risk asso

loss of, 191–192 ciated with use of, xix, 1,
magnitude of treatment 199–200
effects, 229, 230
trial of, 144, 154, 158, 163, 167, 205,
for older adults, 182–183

236, 237, 241, 253, 254
effects on sleep, 162, 183–185, 186,

varying administration schedule
187, 198
for, 189–190
explaining to patient/family, 143

Melatonin, 245
FDA-approved medications, 174

Memory, 20–22. See also Working
fine-tuning for a specific person,

memory
186–187 older memories and shaping of
fitting to patient’s schedule,183–186 current relationships, 67–69
follow-up appointment after initi Menopausal women, xx, 37–38, 94,
ation of, 207

166–167
lack of response to, 143

Metadate; Metadate CD (methylphe
marijuana use and, 192, 195, 253
nidate), 174, 178
mechanism of action of, 87–88,

Methylin; Methylin CT; Methylin ER
172–174
(methylphenidate), 177
misuse or diversion of, xix, 1, 181,

Methylphenidate, 87, 174, 181, 189,
195, 198, 199, 246, 249–250

198, 246
onset and duration of action of,

dosing of, 177–179, 183
185–186
mechanism of action of, 87, 88, 173
for parent, 154

Meyer SE, 242
in patients with anxiety, 235–236

Mild neurocognitive disorder, 94
in patients with autism spectrum

Miller WR, 253
disorder, 255, 256

Mirtazapine, 245
in patients with emotional dys Modern Language Aptitude Test,
regulation, 241–242
147, 239
in patients with learning disor Mood disorders, xix, 6
ders, 240
bipolar disorders, 113–115
in patients with obsessive depressive disorders, 110–113
compulsive disorder, 248

disruptive mood regulation disor
in patients with substance use
der, 114
disorders, 253
elevated risk for, 103, 137
Index 297
Mood stabilizers, 242, 246 Neurotransmitters, 9, 75, 86–88, 130,

Mood status, 136, 137 143, 167, 172–173
More Attention, Less Deficit: Success New model of ADHD, 11–25, 15,
Strategies for Adults With ADHD, 45–46, 103. See also Executive
224 function impairments
Motivation(s), xv, xvii, xviii, 4 action: monitoring and self
emotion-based, xviii, 63 regulating action, 22–23
learning disorders and, 106 activation: organizing, prioritiz
to meet deadlines, 6, 16, 34, 40, 47, ing, and activating to work,
66, 73–74, 120 14–15
older memories and shaping of age-related executive functioning
current interpersonal rela impairments, 45–60
tionships, 67–69 effort: regulating alertness, sus
situational specificity of, xvii, xxii, taining effort, and adjusting
xxiv, 6–8, 61, 74–78, 90–91, processing speed, 17–18
106, 149, 161, 173–174 emotion: managing frustration
neural transmission and, 74–76 and modulating emotions,
reading and, 106 18–20
working memory and, 76–77 explaining to patient/family,
unconscious, 66–67 141–142
Motivational interviewing, for sub focus: focusing, sustaining atten
stance use disorders, 253 tion on tasks, and shifting
MRI (magnetic resonance imaging), attention when needed, 16–17
8, 81, 83 memory: using working memory
and accessing recall, 20–22
NA (Narcotics Anonymous), 252 A New Understanding of ADHD in
Nadeau K, 208, 221 Children and Adults: Executive
Narcotics Anonymous (NA), 252 Function Impairments, 224
National Comorbidity Survey Repli Newcorn JH, 246
cation, 101, 102 Nicolelis MA, 9
National Institute on Drug Abuse, Nicotine use, 91, 123, 135, 250
194 Nonmedication interventions, 203–231
National Resource Center on ADHD, accommodations and legal pro
223–224 tections in employment set
National Survey of Children’s tings, 221
Health, 102 accommodations in college and
Nelson-Denny Reading Test, 147, postgraduate settings, 219–221
239 additional supports, 229–230
Neural transmission. See Electro alternative treatments, 227–229,
chemical communication in 230
brain coaching, 227
Neurofeedback, 228, 230 cognitive-behavioral therapy,
Neurons, 86, 142–143, 172–173 224–225
Neuropsychological testing, xix, collaboration with elementary and
129–130, 148–149, 239 secondary schools, 212–219
Nonmedication interventions (con Oppositional defiant disorder
tinued)
(ODD), 115–117
couple therapy for adults,

ADHD and, 115–116, 137, 245–246
225–226
education of patient/family, 132,

203–206
and, 116–117
guidance for parents, 206–212

prevalence of, 115
supportive psychotherapy for

prognosis for, 246
adults, 221–224
Organizational problems and skills,
Nonstimulant medications, 154, 174,

xxiv, 4, 6, 13, 14, 15, 24, 25, 41,
180, 181, 189, 207

45, 61, 79, 80
duration of treatment with, 195

coaching for, 227

cognitive-behavioral therapy for,
Norepinephrine, 88, 172, 174

225
of elementary school children, 50
Obsessive-compulsive disorder
employment and, 97
(OCD) and related disorders, 6,

of menopausal women, 94
117–121, 247–248
in obsessive-compulsive disorder,
ADHD and, 117–119, 248

248

for school, 50, 161, 162
case examples of, 117–119

college, 220
driver who fears injuring a

test taking, 216
pedestrian, 118–119
writing tasks, 18, 106
religious child who refuses to

Orlov M, 226
attend church, 117–118

Outgrowing symptoms, xvii, 4, 5, 34,
woman distressed about her

95, 210. See also Remission of
husband’s safety, 118

symptoms
young mother who fears hurt Owens JA, 244
ing her baby, 118
DSM-5 classification of, 247

Panic attack or panic disorder,

108–109, 134
and, 120–121
with agoraphobia, 109
prevalence of, 117, 247

treatment of ADHD with, 234, 235
Obstetrical factors, 42
Parent to Parent Program of CHADD,
Obstructive sleep apnea, 223, 244

230
OCD. See Obsessive-compulsive dis Parenting by person with ADHD, 3,
order
57–58, 154, 210
ODD. See Oppositional defiant dis The Parent’s Guide to the Medical
order
World of Autism: A Physician
Older adults with ADHD, 93–94

Explains Diagnosis, Medications &
effectiveness of medications for,

Treatments, 254
182–183
Parents of child with ADHD. See also
1-2-3 Magic: Effective Discipline for

Family
Children 2–12, 3rd Edition, 208

adult relationship with, 35
Index 299
behavioral parent training for, PET (positron emission tomogra

230
phy), 88, 130
as collateral information source,

Phelan TW, 208
132
Philipsen A, 244
communicating with school about

Phillips KA, 248
child’s ADHD, 209–210

Phobic fears, 107–108
fair treatment of all children in

Physical development, 136
family, 211
P.L. 93-112 (Rehabilitation Act of
guidance for, 206–212

1973), 144, 215, 218, 221
losing temper, 69–70, 154

P.L. 94-142 (Individuals with Dis
resolving differences of opinion
abilities Education Act Amend
between, 43, 157–158, ments of 2006), 215
207–208 P.L. 108-446 (Individuals with Dis

about punishment of child, abilities Education Improve
160–161
ment Act of 2004) (IDEA), 144,
resources for, 146, 208, 218–219

215, 218
setting reasonable expectations

Planning and placement team (PPT)
for child, 208–209 meeting, 217–218
Partner relationships, 29, 52, 55, 56–57,

Play, 90, 133, 145
97, 98, 165, 200, 212. See also

in assessment of young children,
Dating relationships; Marriage

145–146
couple therapy, 225–226

of elementary school children,
Peer rejection, 50, 90, 156–157, 212,

50
255
of preschoolers, 48
Pera G, 226
sports, 6, 50, 67, 133, 168, 186,
Perfectionism, 38, 134, 166

189–190
cognitive-behavioral therapy for,

teacher observations of, 213
249
video games, 6, 15, 40, 90, 153,
in written expression, 119, 120,

168, 243, 255
248
Population studies, xxii, 59
Persistence of impairments, xvii, 3,

Positron emission tomography
13, 27, 34–37, 95. See also Adults

(PET), 88, 130
with ADHD; Remission of

Posner J, 188
symptoms
PPT (planning and placement team)
brain development and, xvii,

meeting, 217–218
36–37, 82
Pregnancy, maternal substance
categories of, 35, 95

abuse during, 42
and expectations of young adults,

Preschool children, 3, 5, 12, 80
53
gender and, 35
of, 13, 48–49, 60, 89
Persistent depressive disorder (dys autism spectrum disorder in,
thymia), 110–111, 237

254
Personality traits, 38
collaboration with school, 212
myth of addictive personality, 251

early treatment of, 3
Preschool children (continued)

Psychoanalysis, xiii, 65
modifications of assessment for,

Psychoeducational testing, 144,
144–145
146–147, 215, 238–239
need for extra support, 90

Psychotherapy, 211
oppositional defiant disorder in,

for ADHD with anxiety, 234, 235
116, 246
for ADHD with autism spectrum
resources for parents of, 230

disorder, 255
risks associated with ADHD in,

cognitive-behavioral therapy,
200
224–225
Social Responsiveness Scale for,

couple therapy for adults, 225–226
147
supportive, for adults with
use of ADHD medications in, 199

ADHD, 221–224
Prescription drug misuse or diver Punishment of person with ADHD,
sion, 246, 249–250

90–91
Preterm birth, 42
by parents, 42, 160–161, 211
Prevalence of ADHD, xv, xxii

by teachers, 43
projected increases in, xxvi–xxvii, 2
worldwide, xxi
Quality of life, 3, 168, 233
Prince JB, 245

Quillichew ER (methylphenidate), 179
Prioritizing tasks and activities, xv,

Quillivant XR (methylphenidate), 179
xviii, 14, 15, 23, 24, 40, 41, 45, 130

Quinn P, 208, 220
coaching for, 227

Quirky Kids: Understanding and Help
ing Your Child Who Doesn’t Fit
emotions in, 64–66, 72

In—When to Worry and When Not
expectations for adolescents, 51, 52

to Worry, 146
expectations for adults, 57
by Google vs. human brain, 62–63

Race/ethnicity, 2
hoarding and, 120–121, 248

Ramsay JR, 225, 236
neural transmission and, 75, 173

Ratey JJ, 224
Rating scales for ADHD, xix, 112,
and, 120–121
130, 132, 138, 139, 144, 147
role of amygdala in, 63–64, 173

for parents and teachers, 146, 214
working memory and, 76

Reading tasks and skills, xxv, 6, 16,
ProCentra (amphetamine), 175

17, 40–41, 51, 66, 89, 96, 104–107,
Processing speed, regulation of, xv,

130, 134, 135, 157, 200, 215, 243,
xviii, xx, 15, 24

244

extended time for taking for tests,

216
104, 156, 239

memory problems and, 21, 105

Nelson-Denny Reading Test, 147,
for writing tasks, 18

239
Procrastination, 41, 65, 73–74, 227

reading disorder (dyslexia), xix,
Professional training for ADHD

104, 107
diagnosis and management, xx,

xxvii
treatment of ADHD with, 238–240
Index 301
Rehabilitation Act of 1973, Section

Self-criticism, 166, 167
504 (P.L. 93-112), 144, 215, 218,

Self-cutting, 158–160
221
Self-discipline, 160, 161
Rejection by peers, 50, 90, 156–157,

Self-esteem, xxiii, 43, 227
212, 255
Self-image, 133–134, 153
Relaxation exercises, 245

Self-monitoring, xv, 23, 227
Remission of symptoms, xvii, 4, 5,

Sertraline, 255
34, 37, 44, 53, 95, 210. See also

Sesma HW, 105
Persistence of impairments
Severity of impairments, 4, 28–29
brain structural changes and, 82,

Sexual behavior of adolescents, 52
85
Shame, xxvi, 43, 73, 91, 151, 156, 159,
in depression, 113
165, 166, 221

about declining grades, 161, 163
116
about obsessive-compulsive dis
Report cards, 146, 214
order, 248
Representational models, 68
Shaw P, 111
Restless legs syndrome, 244

Shaywitz B, 104
Rey-Osterrieth Complex Figure Test,

Shaywitz S, 104
129, 148
Shyness, 38, 109, 133, 163
Rief S, 218
Siblings of child with ADHD, 12, 46,
Ritalin; Ritalin LA (methylpheni 90, 92, 96, 134, 142, 166, 211, 220
date), 174, 177, 179

Sinita E, 188
Robin AL, 208, 226

Situational specificity of motivation,
Rollnick S, 253
xvii, xxii, xxiv, 6–8, 61, 74–78,
Rostain A, 225, 236

90–91, 106, 149, 161, 173–174
Rounsaville BJ, 252

neural transmission and, 74–76
Rutter M, 42
reading and, 106
working memory and, 76–77
SAT exam, xxv, 1, 133, 217, 219

Skin picking (excoriation disorder),
Scheffler R, xxvi–xxvii, 2
119, 247
Schools. See Education and schooling

Sleep and alertness, regulation of,
Scientific evidence for ADHD diag xv, 4, 15, 17, 24, 41, 45, 242–244
nosis, xv, xviii

history taking for, 131, 135–136
Section 504 of the Rehabilitation Act

parent support for, 47
of 1973 (P.L. 93-112), 144, 215,

Sleep and arousal problems, 6, 222,
218, 221
242–245, 256
Selective serotonin reuptake inhibi ADHD medication–related, 162,
tors (SSRIs), 255

183–185, 186, 187, 198
for anxiety, 156, 163, 234, 235, 236

of adolescents, 51, 200
for depression, 237

anxiety and, 234, 235
with emotional dysregulation,

bipolar disorder and, 114, 115
242
college support services for, 220
for obsessive-compulsive disor depression and, 111, 237, 242
der, 248
excessive daytime sleepiness, 17,
Self-control, 3, 115
244–245
Sleep and arousal problems (contin Special education services, 58,
ued) 215–216, 217, 254, 255
generalized anxiety disorder and, Specific learning disorder, 103–107.
109
See also Learning disorders
history taking for, 135–136

SSRIs. See Selective serotonin reup
marijuana use and, 194
take inhibitors
medications for, 245
Stahl’s Illustrated Attention Deficit
obstructive sleep apnea, 223, 244

Hyperactivity Disorder, 181
physiological factors and, 244

Standardized tests, 1, 122, 133, 213,
217, 219, 239

Stein DJ, 248
106
Stimulant medications, 174, 181
staying up late, 17, 41, 168, 243

adverse effects and risks of,
treatment of ADHD in patient
197–200
with, 242–245
alcohol use and, 193–194, 253
trouble waking up, 17, 66, 77, 184,

amphetamine preparations, 174,
234, 243–244
175–176
Sleep diary, 245
assessing impact on anxiety and
Sleep-disordered breathing, 244

mood, 187–189
Sleep hygiene, 245

combined with α2-adrenergic
Smart but Scattered: The Revolutionary

agonists, 181, 241, 246
Executive Skills Approach to Help dosing of, 181–182, 207
ing Kids Reach Their Potential, 208

for older adults, 183
Smart but Stuck: Emotions in Teens and

rebound and, 190–191
Adults with ADHD, 165, 169, 220,

signs dose is too high, 190
224
duration of treatment with, 195–196
Social anxiety, 108, 125, 163, 236, 256
Social media, 50, 243

evidence for, 196–197
Social relationships, xxii, xxiii, 3, 29,

factors associated with, 181–182
43, 56, 92, 124. See also Friend for generic formulations,
ships
192–193
loss of, 191–192
125, 126, 254–255
magnitude of treatment
older memories and shaping of
effects, 229, 230
current relationships, 67–69

for older adults, 182–183
peer rejection, 50, 90, 156–157,

effects on sleep, 162, 183–185, 186,
212, 255
187, 198
substance use disorders and,

fine-tuning for a specific person,
123–124
186–187
supportive, 95–96
fitting to patient’s schedule,
Social Responsiveness Scale—Second

183–186
Edition, 147–148
mechanism of action of, 75, 87–88,
Solanto M, 225
172–174
Solden S, 224
methylphenidate preparations,
Sparrow EP, 145

174, 177–179
Index 303
misuse or diversion of, xix, 1, 181,

as self-medication, 91–92
195, 198, 199, 246, 249–250
social relationships and, 123–124
onset and duration of action of,
treatment programs for, 97–98,
185–186 251–253
in patients with anxiety, 235–236 harm reduction approach, 252
in patients with autism spectrum Suicide, xxii, xxv, 59
disorder, 255, 256

bipolar disorder and, 113, 114, 242
in patients with emotional dys depression and, 110, 111, 237
regulation, 241–242
Supportive psychotherapy for
in patients with obsessive adults, 221–224
compulsive disorder, 248
Supportive relationships, 95–96
in patients with oppositionality,
Sustaining attention and effort, xv, 4,
246
6, 13, 15, 16–18, 24, 25, 43, 45. See
in patients with substance use

disorders, 253
Synaptic transmission, 74, 75, 86–87,
secure storage of, 249–250

172–173
varying schedule for, 189–190

explaining to patient/family,
Story memory tasks, 139–140, 144

142–143
Straight Talk About Psychiatric Medi genetic regulation of, 124
cations for Kids, 4th Edition, 181,

stimulant effects on, 88, 172, 173
207
System 1 and System 2 of brain, 8–9
Strattera (atomoxetine), 174, 180, 181,

Szalavitz M, 251, 252
189, 241
Szigethy E, 236
Stroop Test, 148
Stubbornness, 48, 90, 118, 155–156

Taking Charge of ADHD: The Complete
Substance use disorders, xix, xxi,
Authoritative Guide for Parents,
xxii, 6, 29, 91–92, 121–124. See 3rd Edition, 208
also specific substances of abuse Teachers, 43
ADHD and, 121–122, 250–251

ADHD rating scales for, 146, 214
genetic studies of, 124

information about child from,

146, 209, 213–214
ADHD medication use and risk resources for, 218–219
of, xix, 1, 199–200

Teenagers with ADD, ADHD & Execu
in adolescence, 52
tive Function Deficits: A Guide for
avoidance of, 47, 52

Parents and Professionals, 219
elevated risk for, 91, 122, 123, 137

Telephone helpline, 224

Temper outbursts/tantrums, 46, 112,
and, 122–124
136, 241
history taking for, 135, 250

Temperament, 38–39, 132
impact on education, 122

Terminology for ADHD, xvi, xxiii, 11
myth of addictive personality, 251

Test of Variables of Attention (TOVA
patterns of addiction, 121

8.0), 148
during pregnancy, 42
Test taking
recovery from, 97–98, 124, 252

extended time for, 147, 216–217,
school problems due to, 122–123

219, 239
Test taking (continued)

Tricyclic antidepressants, 242
standardized tests, 1, 122, 133,

Tuckman A, 224
213, 217, 219, 239

Tutoring, 43, 133, 229–230, 240
Tetrahydrocannabinol (THC), 194–195

12-Step programs, 97, 252
TOVA 8.0 (Test of Variables of

Twin studies, 4, 33, 79–80
Attention), 148
Tower of Hanoi/Tower of London,

Unbroken Brain: A Revolutionary New
148
Way of Understanding Addiction,
Transcripts from school or college,
251
146
Understanding Girls With ADHD:
Trazodone, 245
How They Feel and Why They Do
Treatment of ADHD
What They Do, 2nd Edition, 208
effective, 98–99
Understood (online resource), 230
geographical disparity in avail Unemployment, 44, 54, 59, 60, 133.
ability and use of, 94

See also Employment
increased impairment due to

United States Medical Licensing
inadequacy of, 94
Examination, 219
magnitude of treatment effects,
229, 230
Vanderbilt ADHD Diagnostic Parent
medications, 171–201
Rating Scale, 214
nonmedication interventions,
Variability of ADHD impairments, 5,
203–231
7, 27–44
parental disagreement about, 43,
age at symptom onset, 30–34
157–158
cognitive abilities and, 39–41
in patients with co-occurring dis environmental challenges and
orders, 233–256 supports, 41–44
anxiety, 234–237 gender and, 37–38
Asperger syndrome/autism how ADHD sometimes becomes
spectrum disorder, 253–256
more problematic, 88–94, 99,
depression, 237
212
emotional regulation and

bodily changes of aging, 92–94
mood problems, 240–242 comorbid disorders, 91–92
learning problems in reading, criticism or punishment for
math, and/or written failures, 90–91
expression, 238–240 environmental adversities, 92
obsessional and/or compul lack of appropriate diagnosis
sive problems, 247–249

and treatment, 94
oppositionality and aggres new challenges without suffi

sion, 245–247
cient support, 89–90
sleep and arousal problems,

how ADHD sometimes improves,
242–245
95–99, 212
substance use problems,

adequate assessment and
249–253
treatment, 98–99
Trichotillomania (hair pulling), 119,

beneficial partner relation
247
ship, 97, 98
Index 305
brain development that WISC-V (Wechsler Intelligence Scale
catches up, 95
for Children—Fifth Edition),
compensatory strategies, 98
147, 238, 239
recovery from substance use

Wisconsin Card Sorting Test, 129, 148
disorder, 97–98 WJIV (Woodcock-Johnson IV Tests
success in work that fits inter of Achievement), 238
ests and skills, 96–97 Women With Attention Deficit Disor

supportive relationships, der: Embrace Your Differences and
95–96 Transform Your Life, 224
intensity of hyperactivity and/or

Woodcock-Johnson Achievement
impulsiveness, 29–30, 95
Test-III, 147
persistence or remission of symp Woodcock-Johnson IV Tests of
toms, 34–37 Achievement (WJIV), 238
severity of impairments, 28–29 Woodcock-Johnson IV Tests of Cog

situational specificity of motiva nitive Abilities, 147, 238
tion and, xvii, xxii, xxiv, 6–8,

Working memory
61, 74–78, 90–91, 106, 149,

aging effects on, xx
161, 173–174
as aspect of attention system, 103
temperament and, 38–39

brief measures of, 139–140
Vineland Adaptive Behavior

context and, 72–74
Scales—Third Edition, 147

definition of, 21
Vyvanse (amphetamine), 174, 176,

emotions and, 62, 65, 69–70
185, 195
marijuana effects on, 194
as a network rather than a brain
Wechsler Adult Intelligence Scale—

structure, 71–72
Fourth Edition (WAIS-IV), 147,

and situational variability of
238
motivation, 76–77
Wechsler Individual Achievement

Test, 3rd Edition (WIAT-III),

Working memory impairments, xv,
147, 238
xviii, 4, 6, 15, 20–22, 24, 45, 61,
Wechsler Intelligence Scale for Chil 78, 169
dren—Fifth Edition (WISC-V),

in adolescents, 51
147, 238, 239

anxiety disorders and, 110, 112
Wechsler Memory Scale, 3rd Edition,

140
computer training programs for,
Wehman P, 256
228–229, 230
White matter of brain, 83–84, 172

conduct disorder and, 117
aging-related decreases in, 93

depression and, 112–113
WIAT-III (Wechsler Individual

in elementary school children, 50
Achievement Test, 3rd Edition),

learning disorders and, 21, 104–105,
147, 238
156, 238, 239
Wilens TE, 207, 245

in menopausal women, 94
Willer J, 146
Willpower, lack of, xvii, xxiv, 8, 10,

and, 117
61, 75
World Health Organization, 34 extended time for taking tests, 216

Worry, 7, 18, 19, 20, 64, 151, 158. See note taking, 18, 119, 219
also Anxiety and anxiety disor
ders Young adults. See also Adults with
about taking ADHD medica ADHD
tions, 223 accommodations and legal pro
about transition from high school tections for persons with
to college, 220 ADHD in college and post
attentional bias and, 109 graduate settings, 219–221
in generalized anxiety disorder, adaptive skills usually expected
109 of, 53–55
history taking for, 134, 136 case examples of
in obsessive-compulsive and 18-year-old who fails in first
related disorders, 118, 119, semester of college,
247, 248 162–164
in panic disorder, 108, 234, 235 22-year-old in conflict with his
of parents, 161, 199, 206 girlfriend and her reaction
phobic fears and, 107 to his ADHD, 164–165
sleep problems due to, 243 college freshman with biased
in social anxiety, 108 motives, 66–67
Worsening of ADHD impairments, college student who thinks his
factors associated with, 88–94, life is hopeless, xxv–xxvi
99, 88–94, 99, 212 resources for, 220–221
bodily changes of aging, 92–94 risks associated with ADHD in,
comorbid disorders, 91–92 200
criticism or punishment for fail supportive psychotherapy for,
ures, 90–91 221–224
environmental adversities, 92 transition from high school to col
lack of appropriate diagnosis and lege, 90, 220
treatment, 94 Your Defiant Child: 8 Steps to Better
new challenges without suffi Behavior, 2nd Edition, 208
cient support, 89–90 Your Defiant Teen: 10 Steps to Resolve
Wozniak J, 242 Conflict and Rebuild Your Rela
Writing tasks and skills, 16, 18, 36, tionship, 2nd Edition, 208
41, 51, 66, 73, 89, 96, 104, 120,
163, 196, 200 Zeigler A, 220
11-year-old who “goes on strike” Zeigler Dendy CA, 218, 220
when asked to write, 155–156 Zenzedi (amphetamine), 175
college support services for, 220
disorder of written expression,
104, 105–107, 215
treatment of ADHD with, 238,
239
excessive perfectionism and, 119,
248
“O utside the Box is arguably the best practical book ever written on ADHD.
Laden with compelling case examples that humanize this condition, the
writing is both authoritative and readable. Overall, the book masterfully blends
Outside the Box
Outside the Box: Rethinking ADD/ADHD in Children and Adults

the underlying science related to ADHD with extremely helpful guidance for
assessment and treatment. It is a ‘must read’ for anyone dealing with ADHD.”
Stephen P. Hinshaw, Ph.D., Professor, Depart-
ment of Psychology, University of California, Berkeley Rethinking ADD/ADHD
“T his book is another example of Dr. Brown’s exceptional ability to convey
complex information about ADHD to a broad audience in easily under-
standable terms yet based on the scientific evidence. It provides not only a fine
understanding of the disorder, its complexity, and its causes, but also a number
of insightful cases and evidence-based recommendations for its management.” A PR ACTIC AL GUIDE
A PR ACTICAL GUIDE
Russell A. Barkley, Ph.D., Clinical Professor of
Psychiatry, Medical University of South Carolina
“T his brilliant book by a superb clinician-researcher compresses a wealth of

vital, practical information into a marvelously user-friendly and engaging
format. It’s chock-full of everything anyone interested in ADHD wants to know,
arranged in such a way that you can find what you want and will never be bored.”
Edward Hallowell, M.D., author of Driven to
Distraction and other books
Outside the Box: Rethinking ADD/ADHD in Children and Adults—

A Practical Guide assails decades-old assumptions and
presents an up-to-date, science-based understanding of this disorder that
causes significant impairment and considerable suffering for 8%–10% of chil-
dren and at least 5% of adults.
Designed for the layperson, as well as for clinicians, the book offers sci-
ence-based answers—in plain, understandable language—to questions such as
“Why are those with ADD/ADHD able to focus very well on a few tasks in which
they have strong interest but are unable to focus adequately on many other
tasks they recognize as important?” “How is ADHD like having ‘erectile dysfunc-
tion’ of the mind?” “Is medication treatment for ADHD more or less risky than its
not being treated with medicine?”
Both down-to-earth and cutting-edge, Outside the Box: Rethinking ADD/
ADHD in Children and Adults—A Practical Guide highlights multiple perspec-
tives on how this disorder affects children and adults who suffer from it, as well
as those who love and care for them.
BROWN
Cover design: Tammy J. Cordova

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“O utside the Box is arguably the best practical book ever written on ADHD.

Outside the Box: Rethinking ADD/ADHD in Children and Adults

“T his book is another example of Dr. Brown’s exceptional ability to convey

“T his brilliant book by a superb clinician-researcher compresses a wealth of

Outside the Box: Rethinking ADD/ADHD in Children and Adults—

Cover design: Tammy J. Cordova

ADVANCE PRAISE FOR

“Professor Brown translates complex science into everyday language.

Thomas E. Brown, Ph.D.

The untangling of the complexity has barely begun....

the mind requires a global view if we are to get anywhere.

As physicians strive to gather more data, to see more, to be more

About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi

Basic Facts and the Central Mystery of ADHD . . . . . . . 1

A New Model of ADHD

EXECUTIVE FUNCTION IMPAIRMENTS . . . . . . . . . . . . . . .11

Differences Among Persons With ADHD . . . . . . . . . . 27

Ways ADHD Can Impair Functioning

at Various Age Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

How is the brain’s “googling” for motivations different for per­

Practical Aspects of Medication Treatments

for ADHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Practical Aspects of Nonmedication Interventions

for ADHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

What are the uses and limitations of nonmedication treatments

Treatment Adaptations for ADHD

With Various Complications . . . . . . . . . . . . . . . . . . . . . 233

How is ADHD treatment adjusted for persons who also have

THOMAS E. BROWN IS A CLINICAL PSYCHOLOGIST

FIFTY YEARS AGO WHEN I BEGAN MY CLINICAL

Throughout the process of writing this book, I have benefitted substan­

Thomas E. Brown, Ph.D.

FOR DECADES, THE DISORDER CURRENTLY KNOWN

Assumption #1: ADHD is a

impairments are more like the difficulties encountered when carrying

Assumption #2: ADHD is essentially just

Assumption #3: ADHD affects mostly

Assumption #4: Everyone has ADHD

Assumption #5: ADHD always starts in

Assumption #6: ADHD is simply a lack of

Assumption #7: ADHD is always

Assumption #8: There is no scientific

Assumption #9: Highly intelligent people

Assumption #10: ADHD is simply a

Assumption #11: ADHD can be diagnosed

Assumption #12: Treating ADHD with

Assumption #13: ADHD is unrelated to

Assumption #14: Most medical and

Assumption #15: ADHD looks pretty

Assumption #16: Once adequate

Assumption #17: Current DSM-5

Assumption #18: ADHD is purely an

Assumption #19: ADHD is really a

Assumption #20: The importance of

Goals of This Book

can seriously disrupt learning, employment, family relationships, social

justed to different individuals, and how it sometimes gets better and

Case Example: A college student who thinks

How is the brain’s “googling” for motivations different for per

Throughout the process of writing this book, I have benefitted substan

Some epidemiologists and other researchers have questioned the ac

1. ADHD is now understood as the impairment of the brain’s self

oping individuals of similar age. Although much of brain devel

times. The incidence of learning disorders, anxiety and mood dis

This inconsistency in motivation and performance is the most puz

The main point here is that executive functions operate automati

that interact in various ways simultaneously. Think of carrying on a con

These executive functions work together dynamically via rapidly re

that includes two major components: 1) a massive proliferation of corti

Many factors influence the level of impairment for a given individ

When considering impairment, it is always necessary to ask the ques

Impairment is present when the person is not able to adequately per

• Behave carefully, avoiding significant risks. Often, preschool chil

• Demonstrate motivation to learn and use age-appropriate aca