The core symptoms of ADHD are developmentally inappropriate levels of impulsivity, inattention, and/or hyperactivity that have been present since childhood. To make the diagnosis in adulthood requires clear evidence that these symptoms have caused enduring difficulties throughout the individual's development, although there can be great variability in the intensity of symptoms and in the settings in which they occur. Finally, it must be determined that the symptoms are not better accounted for by another psychiatric or medical condition.
The scientific consensus is that ADHD is a developmental disorder with genetic and neurobiological underpinnings. Heritability ratios derived from research of the children with ADHD and their parents and from twin studies of ADHD probands are virtually equivalent to those derived in studies of height among first-degree family members, with an average of 80% of the variance being explained by genetics and only a trifle attributed to shared environmental factors (e.g., parenting). The core symptoms of ADHD reflect a neuropsychological profile of impaired executive functioning (associated with the prefrontal cortex) that significantly affects an individual's reciprocal interactions with the environment. In particular, impaired inhibition, planning, working memory, and cognitive processing speed appear to subserve the impulsivity and inattentiveness seen in these patients (Barkley, 1997; Faraone & Biederman, 1998).
From a CBT standpoint, then, these executive function deficits associated with ADHD exquisitely influence core beliefs by affecting the ongoing experiences from which individuals compose personal meaning. Considering the cumulative effects of the many problems associated with ADHD on one's adaptive functioning and ongoing sense of self, the adult with ADHD likely presents for assessment and treatment with a history of problems that may have been encoded in the form of maladaptive beliefs (e.g., "I'm a failure"; "I'm incompetent"). Consequently, the symptoms of ADHD and the reactivation of maladaptive beliefs (and concomitant emotions) routinely disrupt the individual's life, further eroding what is often an already fragile sense of self-efficacy and further impairing the effective execution of cognitive problem solving.
CBT offers a therapeutic approach that acknowledges the supreme difficulties associated with ADHD as well as the need to develop effective coping skills. It illuminates the explicit and implicit beliefs that arise from the experience of living with ADHD and offers a framework that integrates the biological and neuropsychological dimensions of the disorder. The next section outlines the core elements of this therapeutic approach.
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