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Extreme Makeover : The Case of a Young Adult Man With Severe ADHD
Bradley M. Rosenfield, J. Russell Ramsay and Anthony L. Rostain
Clinical Case Studies 2008 7: 471 originally published online 19 June 2008
DOI: 10.1177/1534650108319912
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Extreme Makeover
The Case of a Young Adult Man
With Severe ADHD

Clinical Case Studies

Volume 7 Number 6
December 2008 471-490
2008 Sage Publications
10.1177/1534650108319912
http://ccs.sagepub.com
hosted at
http://online.sagepub.com

Bradley M. Rosenfield
J. Russell Ramsay
Anthony L. Rostain
University of Pennsylvania School of Medicine, Philadelphia

Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent behavioral disorder

among children in the United States. Many of these children continue to experience prominent
functional difficulties through adolescence and into adulthood. Specific impairments common
to adults with ADHD have only recently come to light. The goal of this article is to discuss the
case of a young man, Ralph, who was first diagnosed with ADHD in early childhood. Although
pharmacotherapy helped him function better at school as a child, he encountered newfound
difficulties as an adult, which reactivated his sense of rejection and failure in virtually every
domain of his life. His case illustrates the degree of impairment experienced by many adults
with ADHD and the benefit of a multimodal treatment package, which, in Ralphs case,
included pharmacotherapy, cognitive-behavioral psychotherapy, and marital therapy modified
for adults with ADHD.
Keywords: ADHD; attention deficit disorder; attention-deficit/hyperactivity disorder;
cognitive-behavioral therapy; psychotherapy; couples therapy; adults; communication skills; pharmacotherapy

1 Theoretical and Research Basis

Attention-deficit/hyperactivity disorder (ADHD) is a prominent developmental neuropsychiatric disorder characterized by the hallmark symptoms of developmentally inappropriate levels of hyperactivity, impulsivity, and/or inattention (American Psychiatric
Association [APA], 2000). Although there appears to be no simple, clear-cut pathophysiology, ADHD is known to be a highly heritable disorder (Nigg, 2006). Researchers are currently exploring links between its observable symptoms and functional differences in
different regions and networks in the brain (e.g., Casey & Durston, 2006). Environmental
factors, on the other hand, have been found to contribute minimally to the risk for developing ADHD (Hudziak, Derks, Althoff, Rettew, & Boomsma, 2005).

Authors Note: Address correspondence to Bradley M. Rosenfield, Adult ADHD Treatment and Research
Program, Center for Cognitive Therapy, School of Medicine, University of Pennsylvania, 3535 Market St., 2nd
Floor, Philadelphia, PA 19104; phone: 215-871-6914; fax: 215-898-1865; e-mail: bradrosenfield@yahoo.com.

471

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It is increasingly clear that children with ADHD do not invariably grow out of it on
reaching adulthood. On the contrary, research of the persistence of symptoms of ADHD
indicates that up to 90% of these individuals continue to experience some degree of functional impairment into adulthood (Biederman, Mick, & Faraone, 2000). Results from a
national survey of psychiatric comorbidity in the United States indicated that 36.3% of
individuals diagnosed with childhood ADHD (established by retrospective self-report) continued to meet full Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR;
APA, 2000) criteria as adults (Kessler et al., 2005). This percentage is likely an underestimation of the true persistence of symptoms because the diagnostic criteria were originally
developed for children ages 4 to 17 years old and do not currently include developmentally
appropriate criteria for adults (McGough & Barkley, 2004). Barkley, Murphy, and Fischer
(2008) compiled an empirically derived set of nine symptoms of ADHD that differentiate
adults with ADHD from both a non-ADHD clinical sample of adults and a nonclinical control sample of adults. Relevant to the current case, these symptoms include the following:
is often easily distracted by extraneous stimuli; often has difficulty stopping activities or
behavior when he or she should do so; often has difficulty sustaining attention in tasks or
leisure activities; and often has difficulty organizing tasks and activities. It is further proposed that the age of onset be modified to specify that some symptoms that caused impairment were present before age 16 years (Barkley et al., 2008, p. 192).
Regarding functional impairment, longitudinal and cross-sectional studies indicate that
individuals with ADHD, when compared with non-ADHD controls, report lower levels of
educational attainment, a higher incidence of psychiatric comorbidity than would be
expected by chance, increased risk for substance abuse, greater discord in relationships,
poorer driving records, and not surprisingly, more negative outlooks and higher levels of
pessimism (Barkley et al., 2008; Barkley, Fischer, Smallish, & Fletcher, 2006; Biederman
et al., 2006; Biederman & Faraone, 2005; Murphy & Barkley, 1996a, 1996b; Wilens,
Biederman, & Spencer, 2002). Working adults with ADHD were paid lower salaries, had
more conflict with supervisors, were less punctual, produced lower quality work, had lower
scores on ratings of work performance, and were more likely to be disciplined by superiors than both clinical and community samples (Barkley et al., 2008).
A variety of studies has established the prevalence rate of adult ADHD at around 4% of
the adult population in the United States, with a recent national survey estimating that 4.4%
of adults in the United States fulfill diagnostic criteria for adult ADHD, representing about
8 million adults. Prevalence rates of ADHD found in international samples are strikingly
similar to those found in the United States, with a recent study of countries in the Americas,
Europe, and Middle East reporting an international prevalence of 3.4% (Fayyad et al.,
2007), indicating that ADHD is not a uniquely American disorder (Kessler et al., 2006).
Increasing numbers of adults are seeking evaluation and treatment for issues related to
ADHD, though, unfortunately, it is estimated that only 11% of adults with ADHD receive
specialized treatment (Kessler et al., 2006). These individuals seek help either after having
been diagnosed with ADHD in childhood and seeking treatment to cope with issues in
adulthood, or after learning about ADHD as adults and recognizing that their longstanding
difficulties that previously had been attributed to character flaws, laziness, or other pejorative explanations may have neurobiological underpinnings and, what is more, are treatable.

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473

Medications, particularly the psychostimulants, have been well researched in the treatment of ADHD in patients of all ages, establishing pharmacotherapy as an effective first
line of treatment (e.g., Dodson, 2005). Although medications may lessen core symptoms of
ADHD, these improvements, though impressive, do not necessarily produce positive results
in important domains of functioning, such as social skills, organization, time management,
and confidence. Thus, medications alone may be insufficient treatment for many adults
with ADHD, particularly those with moderate to severe symptoms and complex clinical
presentations.
Consequently, many adults seek adjunctive psychosocial treatment for help managing
the day-to-day effects of living with ADHD. Though there has been comparatively little
research of psychosocial treatments, cognitive-behavioral therapy (CBT) approaches
adapted for adult ADHD have emerged with the strongest evidence base (Ramsay &
Rostain, 2007). Although ADHD is not the result of negative or distorted thoughts, many
individuals who grew up with (often undiagnosed) ADHD may have developed maladaptive beliefs and cognitions that interfere with the implementation of effective coping strategies. CBT for adult ADHD helps individuals to appreciate how ADHD affects their lives,
develop effective coping strategies, and identify and modify cognitions that interfere with
implementation of these coping strategies to enhance resilience and overall well-being
(Ramsay & Rostain, 2008).
The purpose of this article is to discuss the case of a young man, Ralph, who was diagnosed with ADHD and treated with medications in childhood. However, Ralph experienced
newfound difficulties functioning in adulthood when his symptoms directly led to a number of life crises affecting his ability to function at work and in his marriage. The goal of
presenting Ralphs case is to illustrate the degree of impairment experienced by many
adults with ADHD and to describe a coordinated, multimodal intervention approach composed of pharmacotherapy, individual CBT, and marital therapy to address diverse and
complex problem areas in his life.

2 Case Presentation
Ralph is a 30-year-old married, Caucasian man who sought an evaluation at the authors
specialty clinic for adult ADHD. He made the appointment at the behest of his wife, June,
who is a middle school teacher. June was exasperated because her husband had been fired
from nine different jobs during the first 5 years of their marriage, followed by a 2-year period
of total unemployment preceding his evaluation. Ralph lamented, My wife says Im driving
her crazy with my irresponsibility (i.e., unemployment) and social embarrassments.
Ralph presented as a rather cheerful but admittedly socially awkward young man
whose manner made him seem considerably younger than his stated age. He was friendly
and cooperative through the interview process, but had a tendency to blurt out answers to
questions before the examiner could complete them. Consequently, his answers often
missed the mark and periodically spiraled into loosely related tangents. His eye contact was
minimal and he requested the window blinds be drawn as the light reflection through the
blinds is very distracting.

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Ralph said that his goal for the evaluation and for eventual treatment was to save his marriage by finding better ways to manage his ADHD, especially to enable him to secure
employment. He agreed to seek treatment only after his wife threatened to divorce him.
Ralph said that June complained that he did not listen to her and his lack of reliability and
follow-through on promises made her feel disrespected. He said these complaints were similar to those voiced by his parents when he was younger. Ralph had at times briefly sought
treatment in the past but, considering the gravity of his current situation, he now viewed
treatment as his last chance.

3 Presenting Complaints
Apart from responding to his wifes ultimatum that he seek treatment, Ralph confided
that he was highly motivated to learn how to find and keep a job for personal reasons. He
said that it bothered him to have been fired from every job he had had in adulthood, usually because of some combination of recurrent tardiness, inability to follow directions, forgetting important projects, inefficiency, procrastination, and clashes with peers and
supervisors. Although he reported minimal emotional distress, Ralphs expectation that he
would fail in his endeavors, based in no small part on his realistic experiences of being
fired, spurred brief, though intense feelings of dysphoria and hopelessness. He said that,
when stressed, he distracted himself by becoming engrossed on the computer or by puttering around the house, adopting an attitude that everything is going to work out. He
made plans for finding a new job, but did not follow through on steps to achieve this goal.
Ralph effectively avoided short-term distress but was left feeling like a failure, compounded by resulting financial stress and his wifes view of him as a lazy underachiever.
Ralph hoped to improve his relationship with his wife but it seemed that the harder he
tried, the more mistakes he would make. He bemoaned that his wife felt embarrassed to
socialize with other couples because of his numerous social blunders. For example, they
attended a formal fundraising event for the school district in which June worked and he told
an inappropriate, off-color joke to the superintendent and his wife. In another instance he
reduced a restaurant hostess to tears when he made a joke about her weight, thinking she
was out of earshot. The cumulative effect of these various experiences was that Ralph was
left feeling incompetent and pessimistic about his ability to make changes in his life,
though he desperately clung to the notion that things could magically work out for the best
if he found the right job and the right medication.

4 History
It is good practice, whenever possible, to gather corroborative data about developmental
history and childhood symptoms of ADHD from other observers and sources (e.g., parents
or sibling, medical records, and old report cards). However, Ralph said that he did not get
along well with his parents and tried to keep contact to a minimum, thus the assessors relied
on his report of developmental information and his wifes recollection of stories told to her
by his parents about Ralph as a child.

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Ralph was the only child born to his parents. His mothers pregnancy and delivery of him
were reportedly uncomplicated, as was his early development. His father and mother, a carpenter and a stay-at-home parent, respectively, were frequently called by teachers regarding his behavior difficulties in school and were similarly aggravated by his behavior at
home. Ralph remembered having behavior problems as far back as early elementary school,
including getting in trouble for not sitting still and talking out of turn. He said that his
relationship with his parents was always terrible. I never wanted to sleep and I was all over
the place from the time I could stand up. The only thing I could do for an extended time
was play video games. They told me over and over that I was a handful. He grudgingly
acknowledged that they had exhibited some degree of parental concern because they had
sought treatment for him in childhood.
Ralph remembered severe problems from the very beginning of first grade, including
excruciating boredom with classroom activities, inability to focus attention, squirming in
his seat, excessive talking, and blurting out answers in class. Such behaviors resulted in
recriminations from his teachers and parents, though what he recalled as being most frustrating for him was that they thought I was a bad kid for not listening, but I really couldnt do what they wanted and I couldnt make them understand. Ralph also recalled having
no friends in elementary school because other children found him to be annoying. Such
annoyances were the sum result of missing social cues, perseverating on topics when a conversation had obviously moved on, his inability to stop playful teasing, and always saying
the wrong thing.
After being diagnosed with ADHD by a school psychologist, Ralph was prescribed the
psychostimulant methylphenidate in second grade by a pediatrician. Soon thereafter he was
able to start to develop his first friendships, but, kids still got annoyed with (him) a lot.
He responded well to his prescribed dose and his hyperactivity and impulsivity improved,
allowing him to finally concentrate in school and be less annoying to others. By fourth
grade he said that he felt more normal and his grades and social circumstances continued
to improve, though he continued to characterize sitting in class and doing homework as
agonizing boredom.
Ralph was maintained on a stable dose of methylphenidate for the duration of elementary school, middle school, and into high school. By all accounts, he continued to
respond well to pharmacotherapy in terms of improved attention and concentration and
he was considered an average student. During his senior year of high school, unbeknownst to his parents, he started to skip doses of his medications, only taking it when
he needed to study. Ralphs grades tailed off in many classes. He graduated from high
school with his class but grew increasingly anxious about school toward the end. He had
self-doubts that were similar to those he had in elementary school, though he attributed
his lower grades to senior-itis.
Ralph abruptly stopped taking his medication altogether soon after arriving at college,
ostensibly because he reported increased anxiety but he also admitted that he wanted to do
it on [his] own. Although he had been nervous about college, he found college lectures
more interesting than in high school. Ralph joined a choral group and thrived on the structure
and camaraderie that it offered. He received study tips, free tutoring, and class notes from the
smartest guys in the choir. He also was careful to not schedule morning classes because he
had difficulty waking up and getting to early lectures on time. Ralph acknowledged that,

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despite these steps, college was not easy for him. He was somewhat disorganized in his
approach to completing assignments but was proud to graduate with a solid C average.
During his final year of college, during a period of relative stability, Ralph met June. She
said that she found his energy and willingness to express his outrageous opinions to be
attractive. Neither he nor his wife had much dating experience when they met, and neither
had been in a serious romantic relationship. However, they reportedly fell in love and were
engaged to be married within 6 months, not long after their graduation and to the chagrin
of both families. June said that their first heated arguments occurred when Ralph would forget or not follow through on his various responsibilities in planning their wedding.
Ralphs entrance to the real world of the workplace was a rude awakening for him. The
rigidity of schedules, lack of individualized guidance and supervision, emphasis on personal organization, time management, planning, and personal accountability for performance resulted in repeated poor performance evaluations. There was also no end of the
semester to provide an opportunity to start over with a clean slate.
Ralph tended to respond to superiors corrective feedback by becoming defensive, making excuses, and blurting out convoluted explanations that ranged from blame to angry outbursts. Such behaviors invariably led to reprimands, strained interactions, and, ultimately,
termination of employment. His conflicts at work were compounded by his inability to follow rules, misreading social cues, and stubbornness with supervisors. For instance, he often
arrived early or stayed late to compensate for his admitted procrastination and inefficiency
at work. However, these extra hours raised concerns because his employers were legally
obligated to pay him overtime. Although Ralph offered to waive his overtime pay, such
appeals ended in arguments when Ralph was unable to accept no for an answer. These
interactions resulted in him being labeled as high maintenance. Ralph also refused to disclose to his employers the fact he had ADHD because he was ashamed of his condition.
Being unable to keep a job corroded Ralphs confidence and sense of self, confirming his
core belief that he was inadequate.
June and Ralphs first major marital rift arose when Ralph was fired from his first job
during their first year of marriage. His occupational problems over the years were compounded by escalating marital conflicts stemming from Ralph forgetting to pay bills, not
following through on chores, and getting stuck on topics in conversations, all leading to
his wifes perception that he was insensitive to her. Ralph said her frustration with him culminated a few weeks before he scheduled his evaluation when June tearfully pronounced
him an embarrassing underachiever and banished him to sleep on the couch. Ralph said
that he realized his wife had grown increasingly frustrated with the chaos in their marriage,
but hearing that she was considering divorce took him by surprise. He said he now recognized the need to get help.

5 Assessment
Ralph received a comprehensive psychiatric evaluation that included various measures
of adult ADHD. In addition to an extensive history-gathering interview that included his
wifes input on various forms (although she was unable to attend in-person) and psychiatric
records, Ralph was administered the Structured Clinical Interview for DSM-IV Axis I

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Disorders (First, Spitzer, Gibbon, & Williams, 1997), the Brown Attention Deficit Disorder
Scale for Adults (BADDS; Brown, 1996), the Conners Adult ADHD Rating Scales
(CAARS; Conners, Erhardt, & Sparrow, 1999), the Beck Depression Inventory II (BDI-II;
Beck, Steer, & Brown, 1996), the Beck Anxiety Inventory (BAI; Beck & Steer, 1990), the
Beck Hopelessness Scale (BHS; Beck & Steer, 1989), and ADHD symptom checklists for
both childhood and adult symptoms, including both self-report and observer report forms
(Barkley & Murphy, 2006). No school records were available.
Ralph presented with minimal levels of self-reported anxiety and depression, which was
surprising given his precarious domestic and vocational circumstances. Ralphs scores on
the BDI-II, BAI, and BHS all fell in the minimal range for depression, anxiety, and hopelessness, respectively. Thus, these self-report instruments did not accurately reflect the
degree of functional impairment Ralph exhibited. In effect, he was disturbingly underwhelmed by the problems he was facing as a result of various avoidance strategies.
Although he endorsed items on the BDI-II indicating that he was troubled by indecision,
believed he had failed more than he should have, and that he had lost confidence in himself, each of these items was endorsed only as mild. He seemed to find comfort by
attributing his difficulties to his childhood diagnosis of ADHD, seemingly using the diagnosis to explain away his current problems and to deflect the suggestion that he could
develop ways to cope more adaptively.
The BADDS is a 40-item clinician-administered rating scale of ADHD symptom severity
in various life domains. Ralphs BADDS total score fell in the ADD highly probable range
and he had clinically elevated scores for the Activation and Attention subscales, reflecting that
he has difficulties getting started on tasks and maintaining focus on various projects.
The CAARS: Long Version is a 66-item self-report instrument that measures a wide variety
of symptoms of ADHD in adult patients. Among the subscale scores are three devoted to DSMIV criteria (DSM-IV Inattentive Symptoms, DSM-IV Hyperactive-Impulsive Symptoms, and
DSM-IV ADHD Symptoms Total). Ralphs responses indicated clinical elevations for both
hyperactivity/impulsivity and inattentive symptoms and for subscales measuring emotional
lability, inattention, and memory problems, and problems with self-concept.
Ralphs recall of his behavior during childhood, corroborated by a copy of the evaluation report written by the school psychologist who assessed him in first grade, indicated the
presence of sufficient impairment to indicate that he had met diagnostic criteria for ADHD,
Combined Type in childhood. His self-report of his current ADHD symptoms indicated a
developmental pattern of sustained problems of inattention, impulsivity, and poor self-management. Likewise, these impressions were corroborated by his wifes responses on an
observer checklist of current symptoms, with June even adding a note, And this is with
medications [sic] !!! Thus, there was sufficient convergent evidence from a variety of
sources that Ralph had struggled with ADHD since childhood and his current symptoms
continued to play a direct and causal role in his current difficulties.
The structured diagnostic interview revealed a history of brief reactive episodes of
depressed mood, including varying symptoms dysphoria, anhedonia, weight loss, insomnia, and psychomotor agitation that were precipitated by being fired. However, Ralphs
description of his current emotional state fell short of meeting full diagnostic criteria for
severity and chronicity for any mood or anxiety disorder, although he described some residual depressive symptoms. Consequently, the diagnostic impression based on the structured

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interviews, the BADDS, and CAARS results was that his symptoms fulfilled diagnostic criteria for ADHD, Combined Type with comorbid Depressive Disorder, Not Otherwise
Specified (i.e., minor depressive episodes). There was no evidence to suggest that his symptoms could be better explained by other psychiatric disorders or a medical condition.
Results of the assessment were reviewed with Ralph and his wife during an assessment
feedback session. In addition to psychoeducation about the effects of ADHD on his functioning, time was spent reviewing the effects of his impulsivity on his relationship at work
and at home, as these interpersonal issues contributed to his impairment as much as his disorganization and avoidance did. Thus, it was recommended that he start concurrent pharmacotherapy and CBT, with therapy sessions also addressing issues related to his
interpersonal functioning. Considering the level of marital stress, marital therapy with a
therapist specializing in ADHD issues was also mentioned as a possible component of the
treatment plan. Ralph and June said they wanted to discuss this option further, though they
agreed for Ralph to start the combined pharmacotherapyCBT treatment.

6 Case Conceptualization
The symptoms of ADHD are considered to be the downstream consequences of executive dysfunction stemming from impaired neurobiological functioning. The symptoms negatively affect various aspects of self-control, planning, concentration, memory, and
behavioral activation. Not surprisingly, the aforementioned difficulties create many functional problems in the day-to-day lives of affected adults. Ralphs symptoms, which basically had gone untreated in adulthood, created significant impairment in his life and his
could be considered a severe case of ADHD.
Considering the severity of his symptoms and life impairment, it was clear that Ralph
would require multiple modes of treatment. His treatment plan started with concurrent
pharmacotherapy and CBT focused on achieving symptom reduction and functional
improvements in behavioral coping.
At the time of his initial evaluation, according to Ralph and medical records, his previous
psychiatrist had prescribed a combination of extended-release methylphenidate and extendedrelease bupropion, with minimal effectiveness. After reviewing treatment options, it was
decided to switch his stimulant medication to mixed amphetamine salts (immediate release)
and to evaluate how this regimen would help his core symptoms of poor concentration and
inattentiveness, overactivation, and impulsivity. After titrating the dose to a moderate level, he
reported noticeable improvement (> 50%) in these symptoms at which point he was switched
to the extended-release form to improve adherence. Although he was pleased with the initial
response to mixed amphetamine salts, by the 8th week of CBT, Ralph began to complain that
he was extremely unfocused in the evenings and mornings and that these symptoms were continuing to cause significant impairment in his marital relationship and in his ability to carry out
morning and evening self-care routines. After reviewing treatment options, it was decided to
begin a trial of atomoxetine as an augmentation strategy, with the expectation that this medication would be effective in the evenings and mornings, and that it would also enhance the
efficacy of the mixed amphetamine salts. Within a month, Ralph reported that both treatment
objectives were met, and he was very pleased with the results. Not only were mornings and

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evenings easier for him to manage (especially from the standpoint of marital interactions), but
he also found his ability to focus and complete tasks during work hours was significantly
improved (> 70% greater than baseline). He has maintained his progress on this combination
regimen (mixed amphetamine salts, atomoxetine, and bupropion) throughout the duration of
treatment with no side effects.
A CBT case conceptualization provides a detailed template for understanding a patients
belief system and the influence of this belief system on automatic thoughts, emotions,
physiological responses, and behaviors. One of the myths about CBT is that it ignores
developmental information to exclusively focus on the here and now. On the contrary, an
important aspect of developing a case conceptualization is to identify specific developmental learning experiences that may have provided the original evidence for certain core
beliefs; beliefs that may have once been relevant in a specific developmental context.
However, those beliefs may have become obsolete or maladaptive in current settings.
ADHD has pernicious effects on many domains of life that are central for ones selfconcept, such as school, work, relationships, and global sense of self-efficacy. Maladaptive
beliefs, although often rooted in documented frustrations in these life domains, have become
overgeneralized and create undue stumbling blocks to pursuing reasonable personal goals
(Ramsay & Rostain, 2008).
The CBT model of adult ADHD recognizes that the disorder is fundamentally neurobiological in nature (e.g., Seidman, Valera, & Makris, 2005), resulting in downstream deficits
in executive functioning, self-control, and behavior (Nigg, 2006). Despite their neurobiological origin, it is easy to understand how the neurocognitive deficits of adult ADHD contribute to both emotional distress and functional impairment. The effects of ADHD on
functioning are comparable to the notion of temperament, affecting individuals to some
degree throughout their lives and playing an important role in the reciprocal interactions
between oneself and the social environment beginning at an early age. These experiences,
in turn, affect ones self-perception and the personal meanings attributed to new experiences, which, in turn, affect how one constructs core beliefs about oneself, the world, and
ones view of the future (Beck, 1976). In this manner, the individuals core beliefs influence cognitive, emotional, and behavioral responses that then elicit consequences in the
external environment, which serve to maintain the ADHD belief system, in a self-perpetuating cycle (Ramsay & Rostain, 2008).
Based on information gathered during the diagnostic interview and early sessions of
CBT, Ralphs case conceptualization seemed to be organized around three principal maladaptive schema (Young, 1999): failure (Ive failed at everything important in life.),
defectiveness/shame (Im a social embarrassment.), and entitlement (People should
know I have ADHD and accommodate me because I cannot change.). As is common when
constructing a case conceptualization, these beliefs make sense considering that they
arose from recurring, often painful early life experiences, including the sense that he had
disappointed his parents and teachers, primarily because of the effects of his ADHD symptoms. Although he had a positive response to medications and had many affirming experiences in high school and college, his schema lay dormant until triggered by stressful life
circumstances associated with the effects of residual ADHD in adulthood.
To compound matters, Ralph learned that he could immediately reduce his distress by engaging in various forms of avoidance, be it cognitive, emotional, or behavioral. For example, he

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recalled, I could not stand not being able to concentrate on my reading assignments, so I
found excuses to do everything but reading. The benefits of avoidance are immediate, providing quick escape from discomfort (i.e., negative reinforcement). However, costs of avoidance of uncomfortable thoughts and feelings are great, such as dodging important problems
that inevitably must be faced. Ralphs avoidance cycle also prevented him from attempting
more adaptive behaviors and coping strategies that could help him to have more satisfying
experiences. In CBT parlance, such behaviors that are an apparent effort to manage a core
belief but that end up insidiously strengthening them in a self-defeating manner are deemed
compensatory strategies and are an important target for intervention.
It soon became apparent that Ralph also avoided stress by engaging in magical thinking
(e.g., It will all work out), coupled with externalizing thoughts in the form of using the
diagnosis of ADHD to disproportionately emphasize the need for external accommodations
(e.g., They should cut me a break because I have ADHD). These cognitive distortions
served to deflect focus away from the adaptive changes he could make to his coping repertoire. Thus, his tendency to avoid facing various issues in his life out of concern he would
fail was an important aspect of his CBT case conceptualization. These issues would be
important to address as Ralph attempted to make behavioral changes in his life to improve
his functioning and his well-being and, ultimately, to revise his beliefs about himself.

7 Course of Treatment and Assessment of Progress

CBT sessions lasting 50 minutes were held on a weekly basis. During the first CBT session with his individual therapist (BR), the primary agenda item was for Ralph to identify
specific, operationalized treatment goals gleaned from his ambiguous, though understandable objectives, which were to save [his] marriage and find a job. Ralphs ambitions were
reworked into specific behavioral goals, including (a) to learn and use different communication skills with his wife to increase intimacy and deescalate (rather than trying to win)
arguments, (b) to spend 3 nights per week doing specific couples things together, and
(c) to research potential jobs for which he could apply, paying particular attention to issues
related to compatibility and how his attitudes affect his job search and work performance.
Even with well-defined and reasonable treatment goals, the start of treatment for adults
with ADHD is often a delicate time. Ralphs history illustrates the likelihood that these
patients have frequently experienced more than their share of frustration and disappointment. Such biographies can often lead to negative perceptions of treatment, because they
do not see immediate results, particularly in complex cases, such as Ralphs. Thus, it is
important to start small and to prioritize the initial therapeutic agenda to focus on a
highly specific problem that is susceptible to incremental progress (Ramsay & Rostain,
2008). Small problems are very often exemplars of the same patterns and issues creating
big problems. Seeing that Ralph faced crises in both his marital and work domains, he
and his therapist agreed that focusing on issues related to his job search was a good first
step because finding work would address a primary point of contention in his marriage and
hopefully allow him to generate an income.
For Ralph, the first small steps in CBT were further complicated by his ambivalence
about engaging in the process of change. Although Ralph genuinely wanted to find a job

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and improve his marriage, CBT would require him to face issues he had long avoided. What
is more, although crucial to his overall well-being, he seemed to place too much stock in
medications as a cure-all for his problems. Thus, early interventions, during Sessions 2
through 6, also focused on enhancing his motivation for CBT by elaborating on and personalizing his commitment to change, rather than solely being motivated to appease his
wife. In particular, challenging two of his core beliefs, discomfort should be avoided and
Im a failure, required that he take some risks. Therapeutic behavioral change was
reframed as a way Ralph could avoid cognitive, affective, and behavioral difficulties at
work and in his relationships. Thus, his compulsive avoidance was employed in the service
of adaptive change.
With Ralph sufficiently willing to face difficult issues (or at least willing to try), these
early sessions focused on exploring possible job options. When Ralph did not follow
through on a homework task, such as spending 30 minutes researching promising jobs, it
was viewed as a chance for him to explore and understand his avoidance. That is, when
inquiring about the cognitions associated with avoidance (What thoughts went through
your mind when you considered researching jobs?), issues related to pessimism and unrealistic notions of a perfect job emerged, as did problems with poor time management,
procrastination, and disorganization. Each of these potential barriers lent themselves to an
intervention, such as cognitive restructuring (e.g., modify task-interfering thoughts) and
institution of specific coping strategies (e.g., break down project into manageable steps,
keep track of activities in a schedule book, etc.). These interventions provided Ralph with
strategies with which to reapproach homework tasks rather than to avoid and abandon
them. He modified his search for a dream job to one for a job for which he was qualified
and was good enough. Ralph responded well to this win-win approach to therapeutic
homework, that is, either he would complete the task or identify the obstacles preventing
him from doing so.
By Session 8, his insight and adherence increased so that even when he did not follow
through, he was better able to describe the cognitions and behavior patterns that contributed
to his avoidance. Ralph continued to work with his psychiatrist to develop an effective medication regimen during this time, with a focus on further reducing his impulsivity, hyperactivity, and inattention, to enhance his acquisition of new skills. His therapist would
inquire about Ralphs response to medications, his adherence, and the presence of side
effects. Ralph benefited from the fact that his therapist and psychiatrist consulted regularly
regarding his treatment progress.
Despite a generally positive response to medications, Ralph continued to struggle with
procrastination, feeling overwhelmed by tasks that others took for granted, often resulting
in excessive self-criticism. However, each frustration was framed as another opportunity to
develop ways to manage them more effectively. For example, cognitive rehearsal via visual
imagery helped Ralph to think through the steps necessary to update his resume and to
identify the task-interfering thought, There is no job out there that I can do. The feared
fantasy technique (Burns, 1980) was used to further elicit the meaning of this thought to
him, as illustrated in the following exchange:
Therapist (T): What are the thoughts that might prevent you from starting your job search tomorrow?
Ralph (R): [sullenly] Theres no job out there for me.

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T: And if you couldnt find a job, what is the worst thing that you can imagine happening to you?
R: My wife will divorce me.
T: And, for the sake of argument, if your wife divorced you, what would be the worst thing that you can
imagine happening to you?
R: I would be homeless.
T: And if you were homeless, what is the worst thing that might happen?
R: I would be dead on the street.
T: How does that thought make you feel?
R: Terrible . . . depressed.
T: The depression is understandable, given your thoughts. Can I ask you a question?
R: Yes.
T: How likely is it that starting your job search tomorrow will result in your being divorced, homeless, and
dead in the street?
R: [laughter and visible relief] I guess thats a little extreme.
T: Do you see how sometimes our thoughts and expectations can be distorted and how that influences how
we feel and how we behave? In this case, the job search understandably makes you feel bad. Why?
Because it is associated with these very negative thoughts and emotions. However, the short-term gain
of avoiding these negative thoughts and feelings by avoiding the job search ensures that you will not find
a job and increases the likelihood that your wife will divorce you.
R: Youre right. It really is a vicious cycle.

During his early sessions, Ralph had found it helpful to use Daily Thought Records
(DTR; Beck, Rush, Shaw, & Emery, 1979) to systematically develop alternative thoughts
to his pessimistic reactions. These forms helped him produce the following adaptive
thoughts: Im resourceful. Ive gotten married, found other jobs, I have a family. I am
capable of finding another job. I did well in college when I had support. Ralph also used
the forms to temper his tendency to engage in excessively positive magical thinking, such
as, I dont need to practice for the job interview. I think on my feet pretty well, instead
developing the view, Let me spend 15 minutes practicing my answers to some basic questions so I feel prepared.
However, after the progress achieved during the first 10 sessions of individual CBT,
there was one problem that could no longer be deferred. Ralphs wife had stopped wearing
her wedding ring and had informed him she was making plans to leave him and live with
her parents. By reviewing his options in CBT sessions, Ralph saw three potential ways to
respond to the situation. First, he would demonstrate his stability by finding and holding
a job. Second, he would practice relationship enhancement skills (e.g., listening, constructive communication) to reduce his admitted lack of social graces. Finally, Ralph would
invite his wife to couples therapy attempt to improve their increasingly toxic relationship.
In the subsequent individual CBT session, the therapy agenda included the discussion of
principles of effective communication (e.g., Burns, 1980). More specifically, Ralph shared
a recent example of a she saidI said argument with his wife. He and his therapist then
performed a reverse role-play of the same interaction with Ralph playing his wifes role and
the therapist playing a rather impulsive Ralph, so that he experience the argument from her
standpoint. He acknowledged that he did not like what he heard, thus the exercise accomplished its goal of creating empathy and cognitive dissonance, thereby increasing motivation to change. The role-play was then repeated with the therapist, playing a new, adaptive
Ralph, demonstrating communication strategies such as disarming, reflecting, gentle

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inquiry, and empathy, while avoiding defensiveness, name-calling, and interruptions. Ralph
quickly acknowledged that the experience demonstrated how my impulsive interrupting
must drive my wife crazy and that the new method could actually increase the couples
intimacy. Ralph practiced the new strategies in a final role-play as himself, whereas the
therapist carefully shaped his behavior. The rationale for this intervention was to boost
Ralphs confidence and competence, with an eye toward eventually generalizing these
skills to other life domains.
At the start of a Session 12, Ralph announced that he had been offered a job. His
response to the congratulations he received from his therapist, however, was subdued.
Ralph admitted he was considering rejecting the offer. Review of a DTR in session revealed
the following negative automatic thoughts regarding the job: Its a dead-end job. Ill be
stuck there for life. These negative cognitions understandably engendered fright, frustration, and hopelessness. After exploration, Ralph pronounced these thoughts to be distortions and generated the following rational response to them: My fears arent rationalI
wont be stuck. I can still look for a better job after I give this one a fair chance. This is stable pay. Holding a job will show my wife Im serious about making changes.
During the next several weeks, Ralph and his therapist collaboratively targeted his problems at work, including reported personality clashes between a controlling boss and an
admittedly rigid Ralph. From his perspective, disagreements focused on specific details
of how he completed tasks rather than the quality of Ralphs work. Ralph was left feeling
anxious and incompetent and, thus, prone to respond impulsively to his boss. Even
though Ralph could clearly see that this was a risky pattern and he has received excellent
pharmacotherapy, he lacked the ability to manage his frustration, reflecting the cognitive
inflexibility and poor problem-solving often seen in ADHD. Ralph agreed to experiment
with the following procedures at work, which he recorded on a written flowchart that he
could keep with him while on the job:
1. When anxious, take a moment to actively think before responding.
2. Use the DTR to identify automatic thoughts and distortions, and to formulate a rational
response.
3. Communicate to my boss in an assertive but nonaggressive manner, as we role-played in
session, repeatedly.
4. Employ the Three Sentence Rule; that is, limit responses in conversations to two or three sentences to avert lapsing into frustrating tangents and to decrease the probability of inadvertently saying something offensive (J. R. Ramsay, personal communication, January 5, 2007).
5. Listen to my bosss feedback and voice agreement with some aspect of it. Remember,
the primary goal: to communicate to my boss that I hope to do the best job as efficiently
possible.

After a number of successes resulting from this procedure, Ralph and his therapist relabeled Ralph as assertive and collaborative. However, despite these improvements at work
and the fact he was working hard to maintain gainful employment, the deteriorating relationship with his wife was a complicating factor that required a modification to the multimodal treatment plan to include marital therapy. Thus, after about 4 months of concurrent
pharmacotherapy and CBT, June and Ralph agreed to attend marital sessions.

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8 Complicating Factors
Despite decreased conflict in their interactions during the course of his individual CBT,
Ralphs wife reportedly remained skeptical of his ability to sustain his current improvements and new job. Although she remained steadfast in her intention to pursue a divorce,
June reluctantly accepted Ralphs invitation to attend marital therapy sessions. In many
cases, individual CBT for adult ADHD may include periodic sessions with a significant
other to address relationship issues and gather corroborative information about progress
toward treatment goals (e.g., Safren, Perlman, Sprich, & Otto, 2005). However, many couples affected by ADHD seek marital therapy focused on managing the effects of ADHD on
their relationship (e.g., Kilcarr, 2002). Considering the degree of conflict within their marriage, it was recommended that Ralph and his wife meet with another clinician at the
authors program specifically to address marital issues, thus allowing Ralph to continue
individual sessions to focus on his efforts at personal change.
The marital therapist (J.R.R.) had been involved in Ralphs assessment, thus he was
familiar with the case. During their first marital therapy session, the therapist invited Ralph
and June to take turns expressing their goals for what marital sessions could accomplish.
Ralph said that he realized his ADHD symptoms had negatively affected the relationship in
terms of his unemployment and inability to pay attention to his wife. He was optimistic that
CBT would help him improve in those areas but he easily lapsed into anger when he perceived that June did not appreciate his struggles with ADHD or his progress. June
expressed her frustration at being the sole wage earner, compounded by the fact she felt she
was also expected to complete household responsibilities left uncompleted by Ralph. Ralph
fidgeted in his seat while listening to his wife, periodically interrupting with pressured
speech to argue individual points. The therapist reminded Ralph to give his wife an opportunity to speak freely and encouraged him to write down his thoughts on an available tablet
of paper to discuss them later.
The therapist asked the couple each to rate the likelihood they would divorce on a 0 to
100 scale. Ralph replied zero, and his wife shot back 85 to 90. Shocked, Ralph
demanded, How can you say that when Ive made so much progress already in treatment?
The therapist interrupted again to summarize and empathize with each of their frustrations
about the relationship. The therapist pointed out that the purpose of marital therapy would
be to improve their relationship, whether or not they decided to divorce. However, because
the specter of divorce was contributing to the daily stress they experienced, the therapist
asked if they would be willing to put a 3-month moratorium on making a final decision
about divorce. The rationale for this request was to give them time to focus on the issues
that contributed to thoughts of divorce and to implement changes without being in crisis
mode (and there was no evidence of physical or emotional abuse that might have necessitated a separation for safetys sake). Thus, the therapist clarified that this approach would
ask June to temporarily suspend the threat of divorce. This approach also would ask Ralph
to refrain from asking his wife for assurances that she would not eventually proceed with a
divorce to allow them both to focus on making personal changes that would improve their
relationship. June and Ralph both agreed to this plan.
The remainder of the first marital session dealt with starting small and identifying discrete
examples of problems they faced in the context of daily life. For example, a recent argument

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was reverse engineered to elicit the triggering event. June had asked Ralph to pay the cable bill
online because she would be unable to do so while at work. Ralph agreed but apparently had
not heard his wife say (or forgot) that the bill was due by the end of that day. He busied himself with other tasks and figured he could put off paying the bill until the next day. When they
realized the next morning that the bill was past due, Ralphs wife had the automatic thoughts,
He never helps me out. I have to take care of everything. He has no regard for the stress Im
under. Ralphs thoughts were, I screwed up but I didnt know the bill had to be paid today.
She has to realize that someone with ADHD cannot be expected to remember everything. Shes
happy to have something else to hold over me. Although the fact that the bill was not paid on
time was not a distorted thought, the respective partners thoughts illustrated a number of issues
that transcended the immediate issue, such as mind-reading (e.g., He has no regard for my
stress level and Shes happy to have something else to hold over me). Gentle questioning
of these conclusions (e.g., Are there times Ralph does something to help you or that you
appreciate? or Will avoiding the situation help to resolve it?) helped to reestablish a reasonable perspective and decrease their anger with each other in session, allowing them to discuss calmly some of the underlying issues.
The couple was encouraged to discuss alternative ways to communicate and coordinate
specific errands to minimize the occurrence of similar misunderstandings. It was pointed
out that they shared similar goals of getting things done so that they could enjoy their time
together. Ralph was encouraged to share whether or not he thought various coping options
would work with regard to his ADHD, such as how to handle their division of household
tasks. In fact, it seemed that Ralphs discussion of his symptoms and how they made seemingly simple tasks more difficult could be described as intimate communication on his
part insofar as it involved self-disclosure of issues he tried to avoid. In a similar manner,
Junes countenance seemed to soften as she listened to Ralph express his frustrations and
vulnerabilities. Her subsequent efforts to accommodate him (e.g., What if we put a whiteboard on the refrigerator and I write a reminder on there?) seemed almost tender. They
also agreed to reserve at least two scheduled 15-min periods during the week to sit down,
face-to-face and coordinate their schedules and simply spend time talking with each other.
Considering the number of ongoing appointments Ralph had with his psychiatrist and
individual therapist, he and June agreed to attend marital sessions about every 2 or 3 weeks.
The first few marital sessions followed a similar format, reviewing specific difficulties they
encountered and discussing ways to handle them, with time spent each session discussing
ways to enhance their relationship, identifying the impact of ADHD on marriage (e.g.,
Kilcarr, 2002), and reinforcing their ever-improving communication and collaborative
problem-solving strategies. For example, June and Ralph agreed to between-sessions tasks
such as making specific, positive comments to each other (and decreasing unfair criticism),
finding activities to do together, and accepting each others imperfections by monitoring
their automatic thoughts. Ralph made a concerted effort to use the various coping skills discussed in both CBT and marital meetings at home. Sessions grew more relaxed and constructive, there were fewer times the therapist had to interrupt negative interactions, and
Ralph and June both said that their relationship had slowly and steadily improved, though
they were not out of the woods, yet.
With Ralph and Junes permission, the three clinicians involved in Ralphs treatment
consulted over his progress. The psychiatrist was kept informed of Ralphs response to

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medications. The two therapists discussed the various individual and marital issues
addressed in session to ensure that they were providing consistent messages to Ralph and
reinforcing the use of various coping strategies. Although he faced a number of ongoing
difficulties, it was agreed that Ralph seemed to be making slow, steady progress.
Unfortunately, June suddenly dropped out of marital therapy near the end of the 3-month
moratorium (after six sessions of marital therapy) after Ralph demanded that she make a
decision about whether or not she planned to pursue divorce. He said that he had been
growing increasingly anxious about the prospect of divorce despite the fact they had been
getting along much better. Ralph reportedly confronted June one evening, catching her off
guard, and demanded that she owed [him] reassurance that she would not leave him.
Presented with his impulsive, pressured, and rigid ultimatum, and after a lengthy argument,
June said that she had had enough and reverted to her plan to leave him.
The marital therapist made himself available to the couple if they wanted to continue to
work on reconciliation or even to work through a possible divorce. However, June declined
and Ralph was encouraged to deal with resulting coping issues with his individual therapist, whom the marital therapist apprised of the situation. Consequently, 6 months after
completing his ADHD evaluation and starting treatment ostensibly to save his marriage,
Ralph was left to face the crisis of impending divorce and the financial crisis of deciding if
he could afford to continue to live alone in his house.
Although it was not an easy period for him, it is interesting that Ralph was able to maintain perspective and to focus on managing problems as they presented themselves while
keeping up with the demands of his job. He recognized the many improvements he had
made and came to the realization that, This is hard right now, but I have to break it down
to face one issue at a time. I might even be better off without the marital stress.
In the subsequent 3 months, Ralph continued pharmacotherapy and individual CBT. He
took steps to reconnect with his parents and to let them know about his situation with June.
His parents provided him with some financial support that helped him weather the shortterm financial crisis of the separation from June. Ralph used CBT sessions to sort through
and prioritize his personal affairs to clarify his plans. He and June had sporadic contact during the first month or two of their separation to take steps to disentangle their affairs. Ralph
was also encouraged by his individual therapists prediction (based on Junes personality
features, including some moderate abandonment issues) that his absence may, in fact, make
his wifes heart grow fonder.
About 3 months after leaving him (i.e., after 9 months of treatment), June began to invite
Ralph out on casual dates. June did not say that she would reconcile with him but said
that she was not ready to file for divorce. Ralph was ambivalent about this arrangement,
until his therapist asked Ralph if he was willing to tolerate the uncertain situation with June
for another 6 months. Ralph stated that it was not a healthy situation for him and he recognized that he could not afford to continue to pay the mortgage for the house by himself.
He soon thereafter told June that it was unfair to be left in limbo and that he would need
a decision from her either to reunite and resume martial therapy or he would plan to move
on with his own life, including selling their house and splitting the proceeds with her.
Rather than a pressured demand driven by a need to assuage his anxiety or to be vindictive,
he delivered his well-reasoned decision in an appropriately assertive, even-tempered manner. Paradoxically Ralphs assertion that he was ready to leave her finally demonstrated the

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stability and independence that June had wished for from him in the past. After several civil
discussions, June agreed to move back with him and the couple resumed marital therapy
about one year after his initial assessment.

9 Follow-Up
The present case study reflects a one-year multimodal treatment approach for a man with
severe ADHD. Ralph continues to attend monthly booster sessions of CBT to address ongoing workplace and relationship coping issues. He continues on a stable dose of a prescribed
stimulant medication to treat his core symptoms of ADHD. Ralph and June are still married and living together and attend periodic marital sessions focused on maintaining constructive communication and relationship enhancing behaviors. They are working together
on their goal to have children and raise a family.
Finally, Ralph still finds regularly scheduled CBT session helpful to address impulsivity and
communication problems that occasionally crop up and to maintain his positive coping strategies. His improved communication skills and stability have greatly increased his intimacy with
his wife, work performance, and self-efficacy. Although he must continue to be diligent in the
use of his coping strategies, Ralphs improvements have allowed him to modify his belief system and to be more proactive in facing stressors in his life. His assertiveness has generalized
and he finally requested (and received) workplace accommodations.

10 Treatment Implications of the Case

By all accounts, Ralphs case reflects an example of effective multimodal treatment for
a complex case of adult ADHD. He presented for treatment suffering from severe impairment in his occupational and interpersonal functioning. After a year of concurrent modes
of treatment, individual CBT, marital therapy, pharmacotherapy, Ralph had established a
hard-won, though still tenuous, sense of stability in his life.
The twofold implication of Ralphs case is that (a) ADHD in adulthood may contribute
to significant functional impairment requiring comprehensive interventions in severe cases
and (b) adults with ADHD are sensitive to disruptions in the structure of their lives (e.g.,
changing jobs, disruption of relationships, having children) that may require regular and
ongoing booster sessionsserial brief therapyto manage.
Prior to treatment, Ralph experienced significant impairments in a number of life
domains. Consequently, he required a comprehensive treatment approach to, in effect,
makeover many aspects of his life. Effective pharmacotherapy required regular meetings
with a psychiatrist expert in ADHD to find an effective medication regimen to provide adequate symptom relief and provided an important foundation for multimodal treatment.
Weekly CBT sessions built on the foundation of symptom relief provided by medications
helped Ralph overcome an overarching maladaptive belief system that interfered with his
efforts to cope with and overcome the negative effects of ADHD on his life. Finally, marital therapy focused on the distinct contribution of ADHD to relationship difficulties with
his wife. Although interrupted by a separation, marital therapy helped Ralph and June

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60

120

50

100

40

BDI
BADS

30

80
60

20

40

10

20

Behavioral Activation for

Depression Scale (BADS)

Beck Depression Inventory (BDI)

Figure 1
Scores on the Beck Depression Inventory and Behavioral
Activation for Depression Scale by session

0
Pre

10

11

12 Post

Session

recognize how ADHD complicated their relationship issues and to use this information to
start to change their relationship coping and interaction patterns. The combination of different modes of treatment was necessary to target the wide ranging negative effects of
ADHD on Ralphs functioning.
It is also clear that Ralph will likely require ongoing coping support, at least for the near
future. He remains employed in the same job for more than a year and is facing the
uncharted issues related to maintaining adequate performance over the long term. Likewise,
the prospect of raising a family will surely introduce new individual, marital, and family
stressors associated with becoming a parent. The need for ongoing treatment support is not
meant to imply that Ralphs multimodal treatment was ineffective. On the contrary, his coping challenges illustrate that ADHD, particularly in severe cases such as Ralphs, is a lifelong, developmental disorder with pervasive effects that can severely impair functioning at
various life junctures.

11 Recommendations to Clinicians and Students

Many individuals with ADHD who seek help receive inadequate or incomplete treatment
that runs the risk of being only minimally successful at best. Lack of positive outcome most
often occurs in one of two ways. In the first scenario, well-meaning clinicians make capable
efforts to treat presenting problems, such as anxiety or depression without awareness of underlying ADHD. Also, lack of diagnostic accuracy results in treatment that misses the mark
In the second scenario, patients receive an accurate diagnosis of ADHD and treating psychiatrists or primary care physicians provide pharmacotherapy targeting symptom relief. Adult
patients with uncomplicated symptoms may benefit greatly from medications alone. However,
many patients with ADHD may continue to founder because, although the medication has
ameliorated some of the core symptoms, there is not adequate attention paid to behavioral
functioning, including improving organization, problem solving, time management, and social

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skills, and the corrosive effects of negative beliefs that have developed from a lifetime
of frustrations.
Not every patient with ADHD will require the same level of clinical services as Ralph
did. However, Ralphs case illustrates the pervasive impairment that can be associated with
ADHD and the corresponding need for individualized multimodal treatment approaches for
adults with ADHD to address their diverse clinical needs and improve overall well-being.

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Sarasota, FL: Professional Resource Press.

Bradley M. Rosenfield a clinical associate at the University of Pennsylvania School of Medicine, Adult ADHD
Treatment and Research Program, Center for Cognitive Therapy. He is also a clinical assistant professor at
Philadelphia College of Osteopathic Medicine, teaching a doctoral-level class surveying research and treatment for
ADHD. He has lectured internationally to clinicians and academicians on the clinical applications of cognitive therapy, multicultural competence, applied behavior analysis, and persuasion and social influence in the clinical context.
J. Russell Ramsay, PhD, is a licensed psychologist and is assistant professor of psychology in psychiatry at the
University of Pennsylvania School of Medicine. In addition to cofounding and serving as associate director of
the University of Pennsylvania Adult ADHD Treatment and Research Program, he is a senior staff psychologist
at the Center for Cognitive Therapy. He has lectured internationally to mental health professionals on the principles and clinical applications of cognitive therapy and on the assessment and treatment of adult ADHD. His
research interests are focused on developing effective assessment and treatment strategies for adults with ADHD.
Anthony L. Rostain, MD, is professor of psychiatry and pediatrics at the University of Pennsylvania, where
he serves as Director of Education for the Department of Psychiatry. He is codirector of The Childrens Hospital
of Philadelphias Pediatric Neuropsychiatry Program and cofounder and director of the University of
Pennsylvania Adult ADHD Treatment and Research Program. His research interests have focused on improving clinical outcomes for patients with neuropsychiatric disorders, including ADHD, Tourettes syndrome,
Aspergers syndrome, and complex learning disorders. He is triple boarded in pediatrics, adult psychiatry, and
child and adolescent psychiatry.

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