Adults With ADHD PPT - Updated Handout

12/6/23
Adults with ADHD
Continuing Education Workshop

(3 CE)
Natalie Liberman, LCSW, LMFT
natalie@insightwithnatalie.com
(213) 304-6482
insight _with _natalie

© Gerry Grossman Seminars. All rights reserved. 2
Thank you for studying with Gerry

Grossman Seminars!
This workshop was developed by Gerry Grossman Seminars in partnership with AATBS. As such, this
workshop will be attended by both GGS and AATBS students.
Our live online workshops offer an interactive learning environment, with the opportunity to engage
directly with our expert instructors. To enhance the virtual learning experience, we recommend
keeping your camera on for the duration of the workshop. To limit distractions and background
noise, please mute yourself when you are not speaking, but feel free to come off mute to ask a
question or contribute to the discussion.
To receive CE credit for this workshop, participation through polls, discussion questions, and the
chat is required throughout the session.
© Gerry Grossman Seminars. All rights reserved.
1
12/6/23
Thank you for studying with Gerry

Grossman Seminars!
Our live online workshops offer an interactive learning environment, with
the opportunity to engage directly with our expert instructors. To enhance
the virtual learning experience, we recommend keeping your camera on
for the duration of the workshop. To limit distractions and background
noise, please mute yourself when you are not speaking, but feel free to
come off mute to ask a question or contribute to the discussion.
Disclaimer
The information presented in this course is solely intended for
continuing education purposes. This presentation is designed to
support you as a practitioner when making clinical decisions, but it
should not replace your own clinical judgment based on knowledge
of your client. Although general guidelines can be helpful in
determining an appropriate course of therapeutic action, it is
ultimately the responsibility of each individual mental health
provider to formulate the best treatment plan based upon the
unique clinical data presented by the client, in addition to
other relevant information.
Learning Objectives
1. Participants will be able to define FIVE diagnostic characteristics of adult ADHD.
2. Participants will be able to identify FIVE symptoms of inattention and FIVE symptoms
of hyperactivity-impulsivity.
3. Participants will be able to name THREE mental diagnoses that commonly co-occur with
ADHD.
4. Participants will be able to design THREE intervention strategies for supporting clients
with ADHD.
© Gerry Grossman Seminars 6
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Content Outline
vHistory
vDiagnostic criteria and symptoms of ADHD
vDemographics
vCommonly co-occurring conditions
vADHD and relationships
vMisconceptions and stigma
vNeurodiversity
vAssessment
vTreatment
vEthical considerations
vResources © Gerry Grossman Seminars. All rights reserved.
History of Diagnosis
History of ADHD diagnosis

• 1770-75: Melchior Adam Weikard provides first medical description
of attention disorders
• Defined as minimal brain dysfunction in the DSM-I (1952),
hyperkinetic reaction of childhood in the DSM-II (1968), and
attention-deficit disorder with or without hyperactivity in the DSM-III
(1980)
• Updated to attention deficit hyperactivity disorder (ADHD) in the
1987 edition of the DSM-III-R
• Divided into three subtypes in the 1994 edition of the DSM-IV:
• ADHD inattentive type
• ADHD hyperactive-impulsive type, and
• ADHD combined type © Gerry Grossman Seminars. All rights reserved.
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History of ADHD diagnosis

Timeline of ADHD prevalence, medications, and diagnosti
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Diagnostic Criteria
and
Symptoms of ADHD
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DSM-5-TR criteria for Adult ADHD

Ø Five or more symptoms of inattention
Ø Symptoms of inattention are present for at
least 6 months
Ø Five or more symptoms of hyperactivity-
impulsivity
Ø Symptoms of hyperactivity-impulsivity have
been present for at least 6 months
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Symptoms of ADHD
• Inattention: difficulty paying attention
• Hyperactivity: lots of energy, can be expressed physically
or verbally
• Impulsivity: difficulty with self-control, acting intentionally
• DSM-5-TR lists THREE presentations of ADHD:

• Predominantly inattentive type
• Predominantly hyperactive/impulsive type
• Combined type
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Impairment
● Impairment refers to how ADHD interferes with an
individual’s life
● Presence of significant impairment in at least two

major settings of the person’s life is central to the
diagnosis of ADHD (e.g., home, school, or work; with
friends or relatives; in other activities)
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ADHD and Adults

● Many children diagnosed with ADHD will continue to meet criteria for the disorder later in life
and may show impairments requiring ongoing treatment (Pliszka, 2007). However, sometimes a
diagnosis of ADHD is missed during childhood.
● Many adults with ADHD do not realize they have the disorder. A comprehensive evaluation
typically includes a review of past and current symptoms, a medical exam and history, and use
of adult rating scales or checklists.
● Adults with ADHD are treated with medication, psychotherapy or a combination.
● Behavior management strategies, such as ways to minimize distractions and increase structure
and organization, and support from immediate family members can also be helpful.
● ADHD is a protected disability under the Rehabilitation Act of 1973 and the Americans with
Disabilities Act (ADA). This means that institutions receiving federal funding cannot discriminate
against those with disabilities. Individuals whose symptoms of ADHD cause impairment in the
work setting may qualify for reasonable work accommodations under ADA.
● https://www.psychiatry.org/patients-families/adhd/what-is-adhd
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Adult ADHD symptoms may include:

• Disorganization or difficulty staying organized
• Relationship concerns (may come across insensitive, irresponsible, or uncaring)
• Difficulty or lack of focus
• Restlessness and anxiety
• Emotional concerns, low frustration tolerance
• Frequent mood swings
• Hot temper
• Trouble coping with stress
• Hyperfocus
• Time management concerns or lack of time awareness
• Forgetfulness
• Impulsivity (interrupting others during conversation, beings socially inappropriate)
• Negative self-image
• Struggles to stay motivated or lack of motivation
• Fatigue (often due to sleep problems, constant effort to focus)
• Physical health concerns (neglect of physical health: compulsive eating, forgetting to take
medications)
• Substance misuse
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Common problems for adults with ADHD

● Inconsistent performance in jobs or careers; losing or quitting jobs
frequently
● History of academic and/or career underachievement
● Poor ability to manage day-to-day responsibilities, such as
completing household chores, maintenance tasks, paying bills or
organizing things
● Relationship problems due to not completing tasks

● Forgetting important things or getting upset easily over minor things
● Chronic stress and worry due to failure to accomplish goals and meet
responsibilities
● Chronic and intense feelings of frustration, guilt or blame

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What is Executive Function?

o Executive functioning skills help you get things done. These skills are controlled
by an area of the brain called the frontal lobe. Some people describe the
executive function as “the management system of the brain.”
o There are three main areas of executive function, which consists of a set of
mental skills that include:
Ø working memory
Ø flexible thinking
Ø self-control
Trouble with executive function can make it hard to focus, follow directions, and
handle emotions, among other things.
o Executive functions (EFs) makes possible to mentally play with ideas; taking the
time to think before acting; meeting novel and unanticipated challenges; resisting
temptations; and staying focused.
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Executive System has a limited “fuel tank”
○ Every time you use an executive

function, and if you use it
continuously, you empty the
tank
○ And if you get to the bottom of

the tank in the next situation –
you will have NO self-control
○ Hence, it is important to re-fuel

the tank (e.g., small breaks,
meditation, use of visualizations,
exercise)
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Dr. Russell Barkley

ADHD is a disorder of:
• “Performance Disorder, not
skill”
• Knowing vs Doing
• It does not matter what
you know, you won’t use it
• ADHD is considered “time
blindness”
• “Intention” Deficit Disorder
(inattention to mental
events & the future)
• The When and Where NOT
the How and What
https://www.russellbarkley.org/in
dex.html
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Understanding Meltdowns:
The ADHD Volcano Model
The Connect ADHD Volcano model

has been developed to explain and
create understanding of these
challenging and explosive behaviors.
It is an educational model that
represents the relationship between
observable behaviors, diagnosis, core
symptoms, and the underlying
factors of performance influences,
executive function skills
development, and how
neurochemistry underpins all of
these layers.
• ob serva b le b eh a viors a t th e top
• th e d ia gn osis term in ology— core
sym p tom s a n d som e coexistin g
con d ition s
• un d erlyin g fa ctors, p erform a n ce
in fluen ces, a n d th e executive
fun ction skills la yer
• n euroch em istry a t th e b a se
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What are examples of

accommodations that could address
some of the common problems for
adults with ADHD?
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Demographics
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Demographics
● 4.4% of US adults have ADHD; of these 4.4% of US adults
with ADHD, 38% are women and 62% are men
● US psychiatric outpatient clinics shows high rates of adult
ADHD in OP settings: ~15% in the five studies using a two-
stage design and ~27% in the nine screening studies
● Worldwide prevalence of adult ADHD is estimated at
2.8%, with greater rates in higher-income countries
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Demographics continued
● ADHD diagnoses among adults are growing four times

faster than ADHD diagnoses among children in the US
● ADHD is still thought to be underdiagnosed in adults
compared to children
● It is estimated that fewer than 20% of adults with ADHD
are currently diagnosed and/or treated by psychiatrists
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Race
ADHD diagnosis rates among adults of all race/ethnic groups are
rising, but disparities remain (prevalence figures from 2006 to
2017):6
○ White: 0.67 to 1.42 percent
○ Asian: 0.11 to 0.35 percent
○ Native Hawaiian/Pacific Islander: 0.11 to 0.39 percent
○ Black: 0.22 to 0.69 percent
○ Hispanic: 0.25 to 0.65 percent
○ American Indian and Alaskan Native: 0.56 to 1.14 percent
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Gender
From a 2014 review:32
○ Symptoms of inattentiveness are more common in

women with ADHD
○ Women with ADHD are more likely to experience

low self-esteem
○ Anxiety and affective disorders commonly co-occur

with ADHD in women
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Male ADHD
Although men can also present with very similar inattentive ADHD symptoms as
women, both men and boys with ADHD are more likely to display behaviors such
as:
• Hyperactivity
• Disruptive behavior
• Frequently losing items
• Interrupting others during conversations
• Aggressive and defensive behaviors
• High-risk behaviors (e.g., substance misuse, speeding, unhealthy sexual
behaviors, excessive financial spending)
• Angry outbursts
• Insensitivity
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Female ADHD
Here are some possible symptoms of inattention and hyperactivity among women and girls with ADHD.
Some lesser-known ADHD symptoms:
• Feelings of despair, inadequacy and overwhelm
• Lacking motivation
• Disorganized, forgetful and often late
• Being impatient
• Fatigue and insomnia
• Easily losing focus and daydreaming
• Eating disorders
• Hypersexuality
• Prone to body-focused repetitive behaviors such as skin picking, hair pulling, leg bouncing, nail biting or
cuticle picking
• Crying with deep emotion, anger, and feelings of guilt and shame
• Shyness due to social anxiety and sensory sensitivities
• Varying hormone levels can exacerbate ADHD symptoms. This can intensify throughout menopause
• Being a perfectionist
• Difficulty maintaining attention and switching off while others are talking
• Comorbid conditions such as depression, anxiety and OCD are more noticeable than ADHD and are
often treated first
• Anxiety might manifest physiologically in the form of headaches and/or nausea
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How do you think systemic

issues contribute to lack of
diversity in ADHD testing?
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Co-occurring diagnoses
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Commonly co-occurring conditions

• Autism spectrum disorder (ASD)
• Anxiety and mood disorders
• Substance use disorder (SUD)

• Disruptive behavior disorders
• Eating disorders
• Tourette syndrome
• Learning disorders
• Sleep disorders
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What is the most common ADHD comorbidity?

• Anxiety (72% of adults with ADHD; 63% of children)
• Depression (70% of adults with ADHD; 38% of children)
• Learning disabilities (12% of adults with ADHD; 22% of children)
• Sleep disorders (18% of adults with ADHD; 8% of children)
• Sensory processing disorder (6% of adults with ADHD; 14% of children)
• Autism spectrum disorder (9% of adults with ADHD; 13% of children)
• OCD (10% of adults with ADHD; 8% of children)
• Oppositional defiant disorder (10% of children with ADHD)
• Bipolar disorder (6% of adults with ADHD; 3% of children)
• Some estimates are as high as 50% for ADHD people who live with either alcoholism or some
form of substance abuse
• And other conditions like Tourette syndrome, PTSD, and body-focused repetitive disorder
https://www.additudemag.com/adhd-awareness-month-comorbid-conditions/
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ADHD and Relationships
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Rejection Sensitive
Dysphoria (RSD)
William Dodson, M.D.
Dysphoria is Greek for “difficult to bear.”
Rejection sensitive dysphoria (RSD) is extreme emotional sensitivity

and pain triggered by the perception that a person has been
rejected or criticized by important people in their life.
It may also be triggered by a sense of falling short—failing to meet
their own high standards or others’ expectations.
When this emotional response is internalized (and it often is for

people with RSD), it can imitate a full, major mood disorder
complete with suicidal ideation.
https://www.additudemag.com/rejection-sensitive-dysphoria-adhd-
symptom-test/?src=embed_link
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Fight, Flight, Freeze… or Fib?
• As the human brain has evolved, it has developed a self-protective mechanism designed to
ensure survival in times of extreme danger or stress. Faced with a threat, the brain must react
in a split second; deciding how to best protect itself is an instantaneous reaction. This is widely
referred to as the “Fight or Flight” response.
• More recently, the field of psychology has added “freeze” as a significant and common
behavioral response
• Today psychologists are beginning to observe and document a fourth “F” that manifests in
times of real or perceived danger for children, adolescents, and even adults with ADHD: “fib.”
• Often, a “fib” or “fabrication” does allow an individual to avert a present danger or threat, at
least for the time being. The escape from fear, embarrassment, judgment, guilt, or shame
provides a brief but powerful sense of reward (or escape/victory).
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The Fib mechanism protects by:

1. Protection (temporary) from the feeling of having disappointed someone, such
as a parent, teacher, coach, or mentor. Fibbing often follows poor academic
outcomes, incomplete assignments or projects, and missed appointments or
classes.
2. Deflection (temporary) of parental/ significant other anger and the anticipated
consequence.
3. Extension: This may be caused by a desire to “buy some time” in the
momentary absence of information, or information that is not acceptable to the
person that is perceived as a threat. This provides the maker with an extension
of available processing or thinking time. The consequence of the fib is not
planned for.
4. Self-preservation: Preserving self-esteem and self-efficacy; perceived reduced
self- esteem of a “failure” due to an ADHD-related behavior that ended in a
negative consequence, leading to shame and embarrassment.
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Misconceptions and Stigma
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Misconceptions
● Myth #1: "ADHD isn’t a real disorder."
● Myth #2: "ADHD accommodations give people an unfair
advantage."
● Myth #3: "ADHD only affects children, not adults."

● Myth #4: "ADHD only affects boys."
● Myth #5: "ADHD is the result of bad parenting."

● Myth #6: "ADHD medications lead to substance abuse."
● Myth #7: "People with ADHD are lazy or unintelligent."

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Stigma
• People with ADHD can sometimes be misunderstood as:
• impolite
• unreliable
• immature
• weak in character
• emotionally dysfunctional
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Addressing stigma and

misconceptions
• Advocacy and accurate information
• Contact: hearing directly from people with ADHD
• Education: learning more about ADHD and its effects
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What are some ways you can

address stigma and
misconceptions about ADHD?
58
Neurodiversity
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What is Neurodiversity?
• Often refers to autism spectrum disorder (ASD), ADHD,
and other neurological or developmental conditions
and learning disabilities
• Came into use during the 1990s
• Supports self-advocacy and de-stigmatization
• Encourages inclusive, nonjudgmental language
• Grounded in social justice
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What are some ways you can

incorporate more inclusive
language in your own practice?
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Assessment
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Instructions:
Please answer the questions below, rating
yourself on each of the criteria listed. As you
answer each question, select the option that
best describes how you have felt and
conducted yourself over the past 6 months.
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WHODAS 2.0
It covers 6 Domains of Functioning, including:
• Cognition – understanding & communicating
• Mobility– moving & getting around

• Self-care– hygiene, dressing, eating & staying alone
• Getting along– interacting with other people
• Life activities– domestic responsibilities, leisure, work & school
• Participation– joining in community activities
Scores for each domain ranged from 0 (least difficulty) to 100 (most difficulty) with higher scores
indicating a more severe disability
0–4 indicates no difficulty
5–24 indicates mild difficulty
25–49 indicates moderate difficulty
50–95 indicates severe difficulty96–100 indicates extreme difficulty.
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https://www.acesaware.org/learn-about-
screening/screening-tools/
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Treatment
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Treatment interventions
• Medications:
Ø stimulants
Ø non-stimulants
Ø antidepressants
• Exercise
• Behavioral therapies
• Mindfulness practice
• Community
• Time management and organizational support
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Individualization of
attention-
deficit/hyperactivity disorder
treatment: pharmacotherapy
considerations by age and
co-occurring conditions
Figure 1. ADHD treatment guide by age group.

Abbreviations: ADHD, attention-deficit/hyperactivity
disorder; AE, adverse event; AMP, amphetamine; ATX,
atomoxetine; DEX, dextroamphetamine; GXR, guanfacine
extended release; MPH, methylphenidate.
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Ethical considerations
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Ethical Considerations
• Clear communication and support about logistical expectations for
therapeutic care
• Collaborative care with psychiatric providers
• Awareness of news and legislative issues affecting ADHD and
neurodivergent communities
• Advocacy might be needed for work or school-based

accommodations
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Food for Thought…….
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Resources
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Resources from the Webinar

• ADHD Palooza series
• A-D-Diva Network
• Confessions of an ADDiva: Midlife in the Non-Linear Lane (#CommissionsEarned)

• Attention-deficit/hyperactivity disorder as a risk factor for cardiovascular diseases: a
nationwide population-based cohort study
• Mapping phenotypic and aetiological associations between ADHD and physical conditions
in adulthood in Sweden: a genetically informed register study
• Attention-deficit/hyperactivity disorder: is there a connection with the immune system?
• ADHD is associated with migraine: a systematic review and meta-analysis
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12/6/23

Adults with ADHD

Continuing Education Workshop

Natalie Liberman, LCSW, LMFT

insight _with _natalie

Thank you for studying with Gerry

© Gerry Grossman Seminars. All rights reserved.

Thank you for studying with Gerry

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

1. Participants will be able to define FIVE diagnostic characteristics of adult ADHD.

© Gerry Grossman Seminars 6

© Gerry Grossman Seminars. All rights reserved.

History of ADHD diagnosis

History of ADHD diagnosis

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

DSM-5-TR criteria for Adult ADHD

• Impulsivity: difficulty with self-control, acting intentionally

• DSM-5-TR lists THREE presentations of ADHD:

© Gerry Grossman Seminars. All rights reserved.

● Presence of significant impairment in at least two

© Gerry Grossman Seminars. All rights reserved.

ADHD and Adults

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

Adult ADHD symptoms may include:

Common problems for adults with ADHD

● Relationship problems due to not completing tasks

● Chronic and intense feelings of frustration, guilt or blame

What is Executive Function?

© Gerry Grossman Seminars. All rights reserved.

Executive System has a limited “fuel tank”

○ Every time you use an executive

○ And if you get to the bottom of

○ Hence, it is important to re-fuel

© Gerry Grossman Seminars. All rights reserved.

Dr. Russell Barkley

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

The Connect ADHD Volcano model

What are examples of

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

© Gerry Grossman Seminars. All rights reserved.

● ADHD diagnoses among adults are growing four times

© Gerry Grossman Seminars. All rights reserved.

○ White: 0.67 to 1.42 percent

○ Asian: 0.11 to 0.35 percent

○ Native Hawaiian/Pacific Islander: 0.11 to 0.39 percent

○ Black: 0.22 to 0.69 percent

○ Hispanic: 0.25 to 0.65 percent

○ American Indian and Alaskan Native: 0.56 to 1.14 percent

© Gerry Grossman Seminars. All rights reserved.

○ Symptoms of inattentiveness are more common in

○ Women with ADHD are more likely to experience

○ Anxiety and affective disorders commonly co-occur

© Gerry Grossman Seminars. All rights reserved.