Adults with ADD/ADHD: A Population Requiring Support and Treatment

AD/HD is a mental disorder described in the DSM-IV. The phenomenon of adult AD/HD is gaining increasing attention and investigation. In adults, signs of AD/HD may include poor control of attention and focus, excessive or driven motor activity, and poor judgment and impulse control. These problems may result in disorganization, procrastination, and poor attitudes and choices that lead to many personal and professional difficulties. Such difficulties can include injuries, legal and financial problems, relationship difficulties, poor school performance and unemployment or under-employment. Because AD/HD commonly starts in childhood, persons with AD/HD can have highly negative or even destructive self-perceptions and beliefs about people and the world. They may be immature in ways that reflect missed or negatively experienced developmental windows because of rejection by peers, mishandling by authority figures, and similar problems. AD/HD is often accompanied by other mental disorders such as anxiety, learning disabilities, sensory integration disorders, depression, and bipolar disorder. Even impulse control disorders, substance abuse, and serious personality problems are more likely to occur in persons with AD/HD.

Often, a combination of such problems co-occur to constitute subclinical symptoms bearing some resemblance to AD/HD or any of it's comorbidities, and yeilding problems such as those described above. Those problems, though not as severe, may require and benefit group support or treatment of the kind described in this training. Because the level of disability in people with AD/HD varies widely, and because people with subclinical problems resembling AD/HD can have similar needs, a therapy group for persons with AD/HD will need to have entrance policies to ensure an adequately homogenous group. Research so far has not established guidelines for such a determination.

AD/HD is a disabling condition because it causes functional limitations. Because it is a so-called invisible disability, is not consistently disabling, and can be masked to a large extent, it is difficult for many people to think of it as a disability, despite its recognition in the Americans with Disabilities Act and the World Health Organization as a disability. It is important to recognize that therapeutic intervention with AD/HD generally involves more than the kind of improvements in relationships and life adjustment that are narrowly focused or involve a less impaired or neurotic population.
Persons with AD/HD are likely to require habilitation, which means overcoming a disability to obtain a higher level of functioning. Often, habilitation is lumped in with the term rehabilitation, so we will use that term from this point on.

Clinical Challenges and Opportunities

Introduction

This section introduces the reader to clinical challenges in working with AD/HD, and frames them in terms of group work. It is important to recognize that many of the behavioral problems of AD/HD result from the combination of underlying neurological problems and the effect that they have on development in the child's social context over time. Many persons with AD/HD have been practicing dysfunctional coping skills and thinking patterns for many years. This can pose a significant challenge in treatment, even where the client is highly motivated.

Multiple Diagnostic Issues

Because AD/HD is often associated with comorbidities such as bipolar illness, the counselor should be prepared to communicate privately with participants about possible additional assessment and treatment needs. Even a participant who was assessed as being appropriate for a group may, at times, be unable to participate appropriately because of interference by a remitting disorder such as bipolar illness. The counselor bears a responsibility to ensure continuity of treatment. This may take the form of a referral for another level of care. Some new applicants will need to be diverted altogether. Participant needs may be much more serious than stereotypes about persons with AD/HD suggest, and participants may have substantial defenses to recognizing that there are serious needs. This means that the therapist may find it challenging to establish group norms. Some members may initially have difficulty with frank discussion of matters such as abuse of medication, managing the symptoms and treatment of other psychiatric disorders, and coping with very serious life problems such as legal issues, violence, and financial disruption.

It is also important to recognize that AD/HD is a cognitive-behavioral developmental disorder. (Sagvolden, Johansen, Aase, & Russell, 2005) This can lead to a spectrum of difficulties in multiple domains of functioning neurologically and in life and relationships. (ibid)

Metacognitive Deficits and Training (MCT)

Metacognition is the capacity to think about thinking. In cognitive therapy, insight into dysfunctional thought patterns is a therapeutic benefit of metacognitive enhancement. The study of metacognitive deficits and their amelioration is taking place for a number of mental disorders, including schizophrenia. A program has been developed that focuses on amelioration of meta-cognitive deficits in a group therapy format. (Solanto, Marks, Mitchell, Wasserstein, & Kofman, 2008) Even in schizophrenia, it is being recognized that cognitive distortions such as delusions may be remediated with metacognitive training (MCT). (Moritz, Woodward, 2007) This work can be recognized as an extention of cognitive therapy innovations beginning with the 1950's and 1960's as initiated by Albert Ellis and Aaron Beck.

Cognitive deficits vs. organic problems: Here it is valuable to distinguish between cognitive deficits that are directly the result of brain injury and cognitive biases and distortions that are habituated and secondary to brain injury, socialization, and adaptation to disability. "Cognitive biases represent thinking distortions and processing preferences rather than performance deficits and limitations of mental capacity (e.g., impairment in memory accuracy and attention)." (ibid)

Metacognitive Training: MCT involves using various means to make metacognitive strategies accessible to the target population. It may include a discussion of the specific cognitive distortion and related biological challenges, and then use metaphor or an activity to help make the information more meaningful. This can be followed by homework. For example, an MCT program component dealing with depression is described:

"First depressive symptoms, causes and treatment options are discussed. Then, typical depressive cognitive patterns in response to common events are presented (e.g., over-generalization, selective abstraction), and the group is asked to come up with more constructive and positive ones. At the end, some strategies are conveyed to help patients to transform negative self-schemata and elevate their mood." (ibid)

To help clients understand and prevent jumping to conclusions, a picture is assembled. This serves as a metaphor indicating that you won't get the whole picture if you jump to conclusions.

In AD/HD, common cognitive distortions include perceiving only limited options or choices in a situation, highly self-deprecatory responses to certain types of errors or omissions, failure to recognize certain types of social feedback, denial, compensatory fantasies that distort self understanding, and rationalizing dysfunctional coping skills such as avoidance. Most problems disclosed by persons with AD/HD involve an identifiable cognitive distortion. The therapist can help the client see the connection between each negative outcome and the dysfunctional cognitions that contributed to it. This enhances the client's motivation to change the cognitive distortion and replace it with a more functional perspective.

Relationship to somatic approaches: Somatic approaches such as reprocessing of trauma and taking medication, can assist clients in eliminating cognitive distortions, since physiological problems spur these distortions or make them more difficult to understand or perceive. Given that psychosocial group intervention is generally part of a multimodal approach to therapy, psychiatric and individual psychotherapeutic intervention can provide the somatic and more individualized treatment as needed. Some somatic work may take place in a group format.

Overcoming Defenses and Stigma

Introduction

It can be very difficult and disruptive for an adult to become more realistic about their AD/HD symptoms and diagnosis. Clients' intense needs to avoid stigma can drive them to use defenses such as denial. In any clinical context, including less formal groups, this challenges the counselor. It poses a test of the counselor's ability to frame, maintain rapport, and be sensitive to individual perspectives and motivations. There is substantial risk of losing participants who are traversing this developmental hurdle. Younger participants are less likely to be as defended as older ones because of the greater likelihood that they were exposed to these concepts, or exposed in a more orderly and compassionate way.

Stigma

Stigma directed at persons with AD/HD takes many forms. Many participants will not have developed a personal philosophy that helps them cope with stigma. Thus, it is very important to frame and deal with stigma productively and programmatically. Discussing the debilitating aspects of AD/HD and comparing it to non-stigmatized or less-stigmatized disabilities such as blindness or the loss of a limb can help partipants better understand stigma. Discussing examples of unenlightened responses to AD/HD by teachers, mental health professionals, and others can help participants bond and adopt effective responses to stigma. They need to realize that stigma is internalized. Thinking about ways that they have judged disabled persons may help them realize how ingrained this is. This may help them refocus onto constructive rather than reactive responses to the behavior of others that they find offensive. It is helpful to recognize that words such as "stupid" function more as insults than as assessments, and that people are not entirely "stupid" or "smart." Overarching judgements such as "stupid" should be seen as obstacles to solution-focused thinking. The value, methods, and examples of solution-focused and resourceful thinking should be reviewed repeatedly and in detail.
Our growing understanding of the historical and evolutionary psychological bases of shame and stigma are helping us understand it and find ways to help clients overcome the negative effects of these dynamics. Once clients have transcended shame, they find it easier to embrace constructive coping strategies. 
It is helpful to distinguish between normal embarrassment or responsibility and shame. The former can be empowering or function as "information," while the latter can be disabling. Giving examples of how people take responsibility for errors and omissions and contrasting these behaviors with those of shame can be very useful.

Denial

Denial exists as a defense to spare the individual from a challenge that he or she is not psychologically prepared for. Establishing the capacity to cope with the implications of AD/HD is very important for highly defended clients. Addressing denial in a constructive and stepwise fashion can help to retain the participation of such clients. Seeing others discussing AD/HD in constructive terms is helpful. It is important for clients to understand that there is a positive future and that there are many resources for AD/HD.

Compensatory Fantasies

Compensatory fantasies are a prime example of a psychological defense against the implications of failure, marginalization, and stigma that children with AD/HD experience. Nearly all children's comic books adhere to a formula that provides compensatory fantasies. These comics appeal to children who are marginalized because of characteristics such as awkwardness, AD/HD, or being bookish or gifted. A fantasy framework may become so imbedded in implicit memory (unconscious assumed reality) that the person may make very bad decisions as an adult. A common example is that of beginning a business venture based on a belief in management competence that the individual has never actually acquired or proven that they possess.
A tendency to unrealistically blame other people or external circumstances for failures that are obviously attributable to the individual is a strong sign of compensatory fantasy. The same goes for unrealistically positive self-appraisal. Shady business people take advantage of the compensatory fantasy by getting people to invest in unrealistic schemes such as multilevel marketing ventures. Questionable groups, including cults and gangs, have appeal to marginalized people because of the promise of membership, appreciation, and status.
Actively replacing the compensatory fantasy with a functional "inner hero" can help to make denial less problematic. Defining the inner hero according to the sacrifices and contributions that they make according to their values and enlightened self interest can help to cultivate a self concept that is constructive, positive, and realistic. (Vaknin, S., 2008)

Pervasive Needs

Many group participants may come to the group in a beaten down state because of a string of failures and the loss of their psychological defenses. They may be drowning in self-hatred and insecurity at that point because they had never developed adequate defenses and perspectives. These clients can benefit from being shown the relevance of treatment to the areas that are problematic. This can include examples of ways clients have improved their lives.

Social Skill Deficits

Immature social skills and deficits: Many participants may have immature social skills or other behaviors that interfere with appropriate group participation. (de Boo, Prins, 2007) The counselor should be prepared to deal with these matters in group when appropriate by having a relevant process that is engaging and compassionate. Normalizing such behaviors as bring part of a learning process helps to reduce stigma as well as the reactivity of other group members. Group members that are unable to adequately comply with necessary group norms will need to have a private, constructive discussion with the therapist that includes guidance as to what referrals and treatments would fit their needs.

Interventive therapeutic style: Many counselors will not have experience with the need to be as interventive as this population can require. It may seem counter-intuitive to explicitly educate and direct group members about norms such as turn-taking, because it does not seem age appropriate. At the same time, it may be a challenge to be flexible and tolerant of individuals who have difficulty consistently adhering to such norms.
Inoculating group members by normalizing this process of education, directing, and remaining flexible can help reduce reactivity of group members to your role, and to a certain amount of acting out by other participants.

Understanding "AD/HD communication": It is important to understand the communication styles common among person with AD/HD. The counselor who is unfamiliar with these styles is well-advised to participate in group discussions with persons with AD/HD such as by visiting an existing support group of some kind. CHADD and ADDA have such groups in many cities. These are discussion and support groups rather than therapy groups. Openly discussing differences in communication may be very productive. People with AD/HD will say that when they are together with others who have AD/HD, the conversation is very comfortable and productive, but may be hard for the average person to follow or tolerate.

Eccentricity and social exclusion: Some adults with AD/HD will have a history of social exclusion or poor relationships. This is a critical area for intervention because it compounds disability and insulates the client from opportunities necessary for well being such as employment.

Persons with AD/HD may exhibit behavioral characteristics (eccentricities) that can damage their credibility and social capital, depriving them of opportunities for social development and life progress. These behaviors include interrupting, expressing flight of ideas (irrelevance), pressured speech, being unable to keep up with conversation topics, being too interventive or controlling in a conversation, gesturing excessively, showing excessive and disproportionate excitement, moving too quickly in establishing intimate friendship, missing important social cues, appearing to be too self-absorbed, and using excessive sound effects and eccentric reliance on idioms or colorful speech.

These behaviors reflect problems such as poor self regulation, attempts to accommodate for processing deficits, and the need to maintain an excitement level that enhances cognitive functioning and sense of mastery, or a need to navigate the conversation onto topics in which they feel knowledgeable or that they are preoccupied with. Poor recognition of social cues may cause some clients to have developed an expressive style in which their affect "approximates" normal modes of expression, rather than being fully spontaneous. This can cause them to appear false, suspicious, or eccentric.

These characteristics may be charming or less than charming, depending upon the individual and the situation. However, many clients will want to learn to "pass" as more normal or typical in situations in which social climbing, credibility, and opportunities hinge upon conveying a more impressive personal style. The therapist can help clients identify behaviors that can interfere with social acceptance. Treatment can include discussing what situations can benefit from a more mature personal style, and what changes are advisable. However, since people tend to identify with their style as essential to their identity, broaching this subject must be done with sensitivity. Conveying the value of "passing" as an option that can be deployed as needed is a helpful frame. Social skills training (SST) has been shown to be effective for children with AD/HD. A more advanced, adult format is likely to prove valuable for adult AD/HD.

Specific Coping and Success Skill Deficits

Persons with AD/HD often have a strong interest in learning skills that may help them be more successful in various areas of life. Such skills need to address developmental deficits, extreme aversion to tedious tasks, disorganization, and serious time management problems, to name a few.

The counselor should have a clear idea as to how much of this kind of training the group will include. At a minimum, the counselor should have resources that they can direct participants to as well as the opportunity for participants to discuss their strategies. The counselor may wish to incorporate training modules in some fashion. This can range from a programmatic progression that takes place in a closed group requiring consistent attendance, to modules that are provided depending upon the interests of a group with inconsistent attendance. Higher functioning persons with AD/HD may gravitate to a group that primarily focuses on such skills and addresses sophisticated challenges such as those posed by professional careers and business management.

Substance Abuse

It is important to screen for substance abuse, as AD/HD, "is one of the most common comorbid diagnoses with PSUD." (Psychoactive substance use disorder.) (Aviram, Rhum, & Levin, 2001) According to these authors, "recent findings indicate that between 15% and 35% of adults with substance abuse problems had ADHD as children and continue to report significant symptoms of inattention and hyperactivity-impulsivity as adults." (ibid) Symptoms of AD/HD may mask PSUD, delaying diagnosis. These two problems can reinforce each other, posing additional challenges to treatment.
Clients with PSUD should be advised to get treatment for PSUD from an appropriate program. Such a program should be cognizant of the effect of AD/HD on the client. With a period of sobriety, it can become possible to assess the degree to which residual AD/HD symptoms actually exist, and to further the client's progress in habilitation. The treatment team must determine whether the client is at risk for abusing stimulant medication, as the prescriber may want to consider non-stimulant medication that is less likely to be abused when appropriate. Sustained-release forms of stimulant medication are being modified to make them less prone to abuse.

AD/HD treatment has been integrated into relapse prevention training for simultaneous treatment of AD/HD and PSUD. (ibid) The authors' rationale includes the understanding that, "importantly, RP is appropriate for individuals with comorbid PSUD and ADHD because it addresses development of impulse control and tolerance of physiological discomfort. Similarly, RP encourages the patient to begin to recognize internal cues and external triggers. These are important tasks for individuals with substance abuse problems, as well as those with ADHD." (ibid) AD/HD can cause certain situations and responsibilities to cause anxiety or feelings of overwhelm that can constitute relapse triggers. (ibid)
Because people in early recovery experience AD/HD like symptoms that can be as debilitating as AD/HD, it may be useful to conduct groups that combine relapse prevention with AD/HD strategies for people in early recovery (or later recovery if AD/HD symptoms persist) even when those clients have no previous history of AD/HD.

Health Implications

AD/HD and its comorbidities pose a substantial public health problem that extends beyond the commonly cited matters such as unsafe driving and drug abuse risk. Both psychological distress and the intertwined behavioral manifestations such as lack of exercise have significant health implications, particularly in regards to cardiovascular health. Authors of a recent study found that certain psychological factors such as depression elevated cardiovascular risk by 50%. The authors suggest that programs, "...exercise a multimodal therapeutic approach to the psychologically distressed individual at risk for CVD. Specifically, behavioral interventions targeting smoking cessation and increasing physical exercise, as well as blood-pressure lowering and inflammation-lowering relaxation techniques, are best delivered in combination with psychotherapeutic and psychopharmacologic means aimed at directly alleviating psychological distress." (von Kanel, 2008) Chronically negative relationships or the absence of adequate social support are also significant cardiovascular risk factors. A negative primary relationship can increase cardiovascular risk by 34%.

Groups for persons with AD/HD should help participants learn to enhance their health, particularly where common vulnerabilities in the AD/HD population are concerned. This can include getting adequate exercise and recognizing when psychological distress is having an impact on self care. (De Vogli, Chandola, & Marmot, 2007)

Medication and Supplementation

It is important to establish understandings of appropriate use of medication and supplementation. Participants may abuse prescription medication, or engage in unwise experimentation with supplements based on questionable sources of information. In a recent group, a member discussed catching up with work by using Adderall in order to pull all-nighters. This lead to a productive discussion about the immanent consequences of sleep deprivation and the net loss of productivity entailed in such a strategy. Participants and therapists must understand that corporate media such as television are controlled by a small number of corporations that are invested in manipulating public perceptions in ways that are not necessarily healthy. For example, in early 2009, some news broadcasts have encouraged the public to use stimulant medication as "cognitive enhancers," and to use Modafinil to sleep less.

Attendance Problems

AD/HD can pose barriers to consistent group participation. Depression, chaotic life circumstances, financial problems, losing track of time and appointments, and social isolation can all contribute to poor attendance. Difficulty coping with threats to psychological defenses has already been discussed.
The counselor should help participants mitigate against factors that threaten attendance. Therapists should consider instructing participants to post reminders in conspicuous places, providing group emails, and advising clients to solicit help in remembering from significant others.

Ticket to Codependence

AD/HD appears to be a primary cause of codependence.  This is because of the vulnerability of persons with AD/HD to become distracted and preoccupied by exciting situations. Also, marginalization of persons with AD/HD may drive them toward less-desirable partners. The codependence movement of the 1980's characterized codependence as resulting from dysfunctional rules learned in childhood. However, many of the characteristics ascribed to codependence conform to AD/HD traits. Many people who describe themselves as being in a codependent relationship attest to childhoods in which there were no rules or role models that promoted codependence. Preoccupation with a dependent partner at the expense of perceiving other choices is a vulnerability of AD/HD for a number of reasons. Not the least of these is that a dependent partner can be part of a compensatory fantasy.  
Therapist should assess for relationship problems, and take an AD/HD-centric perspective on codependence. Also, there are numerous typical human traits that lend themselves to codependence but that are not in themselves pathological. Bonding and attempting to provide caretaking to a person in need are normal behaviors. However, they can become dysfunctional over time in relation to a person who has chronic dependency problems and manipulates their partner.

Cognitive and Learning Issues

Persons with AD/HD may have cognitive, learning, or sensory integration problems that make it difficult to follow certain kinds of presentations and discussions. Although a stereotype of persons with AD/HD is that they are gifted or absent-minded professors, research has shown that the IQ distribution for persons with AD/HD resembles that of the general population. At the minimum, prepare for such challenges by discussing with participants any learning or comprehension difficulties they may have had. It may be possible to accommodate the learning needs of such clients. This can include carving out a smaller aspect for them to work on during the week, providing the program through multiple media or a hands-on approach, or providing more metaphors and colorful examples or stories. It may be therapeutic to assist a learning disabled member to cultivate and maintain self esteem while accepting that they are not getting as much of what is going on as other members. This experience will be a familiar one to them, but in group they can work on this as a self esteem and adaptation issue.
A key to maintaining focus and attention for the psychosocial component in particular can be to have short segments and significant frequent changes in the mood of the presentation. The therapist can model their presentation style after presenters such as motivational speakers, comics, and language instructors who are noted for commanding attention, motivating, and getting ideas across.

Post Traumatic Stress Disorder

AD/HD and PTSD have a great deal of symptom overlap as well as comorbidity. Current theories postulate that there are common biological risk factors in addition to a higher risk of traumatic experiences that result from AD/HD behavior. (Adler, Kunz, Chua, Rotrosen, & Resnick, 2004). Also, the high concordance between parents and children in having AD/HD means that children with AD/HD may be more likely to have disruptive or traumatic childhood events. Family systems themselves appear to be at greater risk for breaking down in terms of job problems, cost burden, stress, and divorce and separation on the part of parents of children with AD/HD. (Coghill, Soutullo, d'Aubuisson, Preuss, Lindback, Silverberg, & Buitelaar, 2008) 

Referrals for treatment of PTSD may be required, and PTSD self-care and recovery may be appropriate as an aspect of AD/HD groups. This is not only because PTSD is common among persons with AD/HD, but because sublincial PTSD-like symptoms are pervasive. One reason for this is the "death by 1,000 cuts" version of trauma that is experienced by persons who have experienced a very high number of troubling experiences. Such experiences include being mishandled by authority figures and being rejected, taunted, or exceeded by peers. Such self-care and recovery is an area that needs research scrutiny. The author has received good feedback from group participants regarding training in Emotional Freedom Technique and similar measures as means of reducing reactivity and improving sleep. While its underlying theory appears to be superstitious, it's procedure resembles numerous other self-care and professional approaches to reducing anxiety and other trauma symptoms. (Yourell, 2009)

Depression

Clients may be experiencing depression that stems from a variety of sources. The AD/HD population experiences elevated levels of  stigma, chaos, under-employment, regret, and self deprecation. They generally use dysfunctional means of achieving alertness and feelings of mastery, and attempt to use productivity strategies that seem to work for everyone but them. All of this can create and compound situationally-based depression. Additionally, depression is comorbid with AD/HD for genetic reasons as well. Thus, it is important to include information about depression and its treatment. This module should emphasize how depression can negatively alter thinking patterns and what clients can do to recognize and respond to this problem.

Anxiety

Persons with AD/HD are vulnerable to anxiety for a number of reasons. Procrastination is spurred by anxiety. Thus, overcoming procrastination can be a very important element of an AD/HD psychosocial education program.

Even extraverts with AD/HD may have a substrate of anxiety that results from having a history of social difficulties and problems with authority figures. Anxiety combined with a strong aversion to tedious, unwanted tasks and an avoidant style is a powerful formula for procrastination common among persons with AD/HD. 

Differential Diagnosis

The diagnosis of AD/HD is often applied, or self applied, in error. Persons with learning disabilities, PTSD, cognitive impairments, and dissociation are likely to be erroneously diagnosed with AD/HD. Although there may be substantial symptomatic overlap between the actual diagnosis and AD/HD, poor screening may result in a group makeup that is not sufficiently heterogeneous. Some persons with AD/HD will be too compromised by another disorder to be appropriate for a given group.

A client with borderline personality disorder may be too interpersonally and emotionally disruptive. One with serious cognitive deficits may not be able to adequately understand and keep up with the group. A client with very late onset AD/HD resulting from recent brain trauma may not adequately identify with members who have dealt with the problem throughout their lives as a developmental disorder. Client screening should achieve adequate homogeneity for the purposes and demands of the group.

Vicious Cycle, Therapeutic Opportunities

Overtly neurological problems such as distractibility and impulsiveness can interfere with social involvement and attracting mentors. They can also interfere with coping skill acquisition and use. These factors can in turn lead to many failures that deprive the individual of resources that could be employed in rehabilitation. These resources include self esteem, functional attitudes, financial resources, and experiences that spur continued adult development. This lack of resources, including dysfunctional attitudes and coping, can maintain, worsen, or initiate further failures and comorbid mental and emotional disorders, creating a vicious cycle of impairment. (Safren, 2006) There are numerous points in this cycle that are amenable to intervention, and it is typically recommended that this disorder receive intervention at multiple points, usually through psychopharmacy, psychotherapy, and psychosocial training. Psychotherapeutic group intervention can combine elements of psychotherapy and psychosocial training.

Less Formal Groups

Introduction

In contrast to therapy groups, support groups emphasize it's membership as it's primary resource for change, and generally do not make use of clinical professional leadership. For the purpose of this training, support groups will be discussed because of their usefulness as potential referral targets, and because some of their practices and benefits can be imported into clinically led groups. Self-help support groups can provide significant assistance for mental disorders and related problems. (Solomon, 2004, Kyrouz, Humphreys, Loomis, 2002)

Existing Programs and Resources

Support groups for people with ADD can be found in most cities. They are often sponsored by an entity such as a hospital. Many are grass roots meetings that take place in churches or other meeting places. Social networking applications such as MeetUp.com can help to facilitate group development and member acquisition.

Participant Expectations

Participants in support groups should be informed of normative group expectations such as the following:

Confidentiality: Although the same legal control of confidentiality that is presumed in individual treatment cannot be assured in a group format, members can be asked to respect each other's privacy. They should also be told to consider the potential consequences of revealing information that would be too compromising in case any member spoke too freely in the community.

Safety: Members can be encouraged to address any concerns about physical safety through open communication and taking action as needed.

Dignity: This might also be referred to as emotional safety. The group members are encouraged to afford one another a basic level of respect. This can be reinforced with the idea that all members are in the group to overcome serious problems, and that solutions are more important than judgment and that members should not attempt to police one another's personalities.

Focus: Members can be reminded of the purpose of the group as being the primary focus. The degree to which unfocused social interaction is allowed can be spelled out. Generally, it is kept to a minimum and mostly occurs as the group is gathering, and after the official ending time. Some groups foster external socialization, while others discourage it.
Social support: In support groups, social support comes in many forms. An important one is that members share what AA refers to as "experience, strength, and hope." Over time, members can experience significant shifts in their thinking and priorities through the psychological impact of this kind of socialization.

Problem solving: Some groups encourage time for focus on specific problems. People can announce at the beginning of the group if they would like the group to focus on a particular issue. Depending on how many such issues are brought up, the group can manage the time spend on each issue in an effort to address all the issues if it is deemed appropriate.

Information: Members can share tips on resources such as the quality of treatment professionals, books, audio programs, and online forums.

Benefit of life experience: By emphasizing what is working best for the members, they are providing encouragement to adopt effective means of coping, and they are providing role modeling for the other members. At the same time, honest acknowledgment and discussion of challenges and setbacks can help members realize that they are not alone with their problems, and recognize the nature of the challenges they and others face.

Clinical Leadership

Support groups may be purely grassroots or benefit from clinical leadership of some kind. This leadership can range from basic facilitation to a more interventive and programmatic approach that is shy of a fully clinical treatment program, as addressed in the section on therapy groups. It is essential that the group understand the nature of the services being delivered, and that the professional recognize that professional ethical standards and laws apply in this context. So long as the professional is making known their license or other qualifications, they are creating a presumption in the group that they will adhere to professional standards, even if the professional does not directly claim to be providing such services.

The counselor should have competent supervision and legal consultation as needed regarding when and how to maintain records, screen and assess, and follow up with members. The policies established for the group should be discussed with the group as an aspect of informed consent.

Care must be taken to prevent malpractice claims for a group that is primarily for public education, for introducing the public to available services, to facilitate informal discussion, or for a programmatic educational approach. Such limited intent should be made clear verbally and in promotional materials that are maintained as a part of the record of group formulation and policies. This may serve as a defense against a claim that the group was of a clinical nature. However, the counselor must consistently comply with the policy. The other policies, such as those regarding attendance, must also be consistent with this intent.

Paraprofessional Leadership

Paraprofessional leadership has been shown to be helpful in support groups, particularly when the group is manualized to some degree. Clinical programs often use paraprofessionals and group formats to save costs and make treatment accessible to a broader population and in larger quantity. Such programs generally have some form of training to ensure that a specified level of quality is maintained.

Support group guidelines

A support group should have overt guidelines and purposes spelled out. Here are example items from the DuPage County ADD Support Group:
Our Mission at DuPage County, Western Suburbs of Chicago, Adult Attention Deficit Disorder ADD Support Group is to: 
Create an atmosphere of honesty, trust, and confidentiality where AD/HD adults can know we are not alone.
Provide education and information about Attention Deficit Disorder.
Learn strategies to better manage our ADHD filled lives.
Give one another emotional and spiritual support.
In Life:

As ADD'ers we have spent our lives feeling blamed, criticized and misunderstood. Therefore, support, encouragement, acceptance, and understanding are essential to recover from the affects of AD/HD.
In our Dupage County Western Suburbs of Chicago Support Group:

1. We have an opportunity to tell our story to fellow ADD'ers who witness and empathize with our past and current struggles.
   
2. We encourage one another by sharing our struggles with ADHD, acknowledging gains and understanding losses.
   
3. We hold each others' vision by reminding us of our goals and encouraging us to continue reaching for them.
   
4. We clear the way for change by allowing us to vent and complain so we can move ahead.
   
5. We provide a structure of meeting regularly, allowing us to consistently report our progress and setbacks.
   
6. We give one another feedback and support telling us what they see us doing.

Meeting Format

It is helpful to have a predictable meeting format. Here is an example from the Naperville ADHD support group:
Introduction and Announcements
ADHD Topic- Speaker or Educational
Break into small groups for discussion
Return to big group for closing
Adjourn to Max & Erma's 

The 12 Step Approach

Introduction

Since the inception of Alcoholics Anonymous, many attempts have been made to adapt the twelve step approach to other problems with varying degrees of success. This training will not attempt to cover twelve step approaches in depth. Readers interested in exploring this may benefit from learning more about Neurotics Anonymous, Emotions Anonymous, and the larger Codependents Anonymous, because these groups pertain to emotional issues rather than addictions. It is difficult to assess the effectiveness of twelve step programs, and even AA is controversial in this regard, with very conflicted research outcomes. (Tonigan, 2001, Harvard Mental Health Letter, 2003)

Problems

Metaphysics

Religious basis is not relevant to all participants. Even the translation of God into "higher power" implies a metaphysical basis for the approach. People who do not subscribe to a metaphysical theory may translate higher power variously into ideas such as being more relaxed about accepting what life brings or accepting that one has a greater potential than is immediately obvious, and that tapping into it can be beneficial.

Lack of Knowledge

The approach developed in the absence of a great deal of new knowledge regarding mental health and behavior change. In the book The Twelve Steps: A Guide for Adults With Attention Deficit Disorder, the reader is told in step one that, "We admit that we can't continue the illusion of control. If this means that all the balls fall to the ground, then so be it. We are so tired of juggling our lives that we are ready to accept whatever comes."
On one hand, this can be part of preparing an open mind, redirecting one's focus from fear of negative consequences to a focus on resourcefulness, and being more realistic about the impairment of ADD. In keeping with that, the book recommends various kinds of assertive self-advocacy. On the other hand, one could derive very negative ideas from this quote without adequate additional understanding and context.

Questions of Relevance

Successful twelve step programs are about recovery from a form of dependency, so applying this to a neurological problem with diverse forms of expression raises questions as to how to best adept the approach for this purpose.

Variability of Meeting Quality

Twelve step programs rely on the experience of their members and do not have a primary leader. Even in well-established twelve step programs such as AA, the value of any given meeting may be poor or even destructive, depending on who is in attendance.
Most twelve step programs have not achieved the level of organization, experience, and infrastructure that AA has. This means that members are less likely to benefit from consistency, quality information materials, member experience, and mentoring. The clinician should not assume that a twelve step group will be of benefit.

Lack of Research Support

Research on the effectiveness of AA does not yet provide enough support that AA is a highly effective approach. It is difficult to draw conclusions from research because of the variability of individual AA meetings. However, there are studies with random program assignment and significant numbers of subjects which have poor outcomes relative to professional treatment or even no treatment. As of this writing, there is no research

Some Potential Advantages

Relevance

There are many similarities between ADD and addiction. The most glaring being that people with ADD have a greater vulnerability to addictions. The twelve steps refer to problems and changes of perspective that many people with ADD can relate to. The first step refers to recognizing that one's life is not working, for example. (Friends, 1996)

Overcoming Denial

A key to ADD habilitation is to recognize the disabling nature of the condition and the need to take measures that the average person does not need. The common complaint of alcoholics that they cannot drink like other people so not unlike that of people with ADD who say they cannot manage time like other people.

Support Group Benefits

Many of the benefits of other group support programs are embodied in the twelve step approach.

Structure

Twelve step groups are structured in such a way as to avoid some of the problems that can occur in support groups. For example, the prohibition of cross talk can help to maintain a group focus on, "experience, strength, and hope."

Mutual Outside Support

A coping strategy that will help some participants is to team up with others for success. The mere presence of another person during a time designated as work time for tedious tasks such as paying bills can help to keep the client from procrastinating. On the other hand, two persons with AD/HD may realize too late that they have conspired to distract each other. Thus, participants need guidelines and support to use peer or other support effectively. Because people with AD/HD are so strongly affected by their situation and surroundings, there are many ways that friends, family, and employers can assist them. However, persons with AD/HD must exercise caution about disclosing their AD/HD in ways that may compromise their careers. Generally speaking, they should be advised to avoid disclosure in all but their most intimate relationships until they have had ample time to think through the consequences of disclosure. Becoming familiar with AD/HD can cause people to forget that the rest of the world has many misconceptions. Employers are motivated to discriminate against persons with disabilities, particularly so-called invisible disabilities such as AD/HD. Such discrimination can occur in many ways that existing law cannot address. 

Drop-In Coaching Format

Introduction

The drop-in coaching group format is a hybrid of an informal support group and a professionally led group. It resembles an informal support group because there are no demands for consistent participation, and because the topics and structure of the group are dependent on the needs of the participants who come to any given meeting. At the same time, the group offers a professional coach or therapist to facilitate and provide other services. Prior to preparing this training, the author acquired five years of experience leading this kind of group as a free or low-cost community service.

Pros and Cons

Gateway Experience

A low-demand offering of service can provide a gateway to additional services and actual treatment. This can occur by building experience and trust with the coach or clinician. It can also serve to educate participants about available services. This may be the only way to reach participants who would not come to a therapy group.

Buffet Experience

By offering diverse modular experiences, such a group can occupy a "take what you need" niche. These experiences can include focused problem solving, discussion of community and online resources, mini-program presentations regarding issues such as time management, open question and answer sessions, and brief presentations by other service providers. The experience can depend on the expertise of the provider. Each session can include a number of different components.

A Community Service: Answering Questions, Providing Referrals

This format can attract people with questions and concerns about AD/HD, and who have not had adequate prior professional input. Thus, the professional must be clear as to what level of questions he or she can entertain, and how far they can go in discussing diagnostic considerations. The clinician can bring up considerations that should be taken to an appropriate professional for further assessment. This group format is an opportunity to correct misconceptions that people in the community have about AD/HD. Generally, such people will have concerns about their own symptoms, and need help in putting them into perspective.

Drawbacks

People with AD/HD generally stand to benefit from a more comprehensive experience. It is important to make sure that participants do not get the impression that this kind of offering is necessarily adequate to meet their longer-term needs, or that it is representative of a therapy group offering, especially where consistent attendance is not required, and where screening is not conducted. As mentioned earlier, having formal policies and an informed consent procedure is recommended.

Two Types of Coaching Groups

This format may attract high-functioning individuals who want to improve their success. Thus, it may be best to distinguish between a group that is more oriented toward people who are naïve to AD/HD, and a group that is more success strategy focused. Where there is adequate demand, the higher functioning individuals should be offered a more structured program that caters to their needs.

Online Forums

Introduction

Online support forums can provide support in communities where no support groups exist, they can augment such support, and can stand on their on as substantial support services. As of this writing, a very popular online forum is www.ADDForums.com.

Benefits

Anytime, Almost Anywhere

So long as the participant has online access in some form, disorganization, isolation, and depression are less likely to interfere with group participation when it is online. This is because the participant messages are threaded discussions that remain available around the clock. Also, with membership available world wide, a great deal of participation can be elicited. With competent management, problem participant posts and spam can be kept to a minimum and eliminated when it appears. Participants who are reticent about participating can "lurk" by merely reading and benefiting from member posts. There is no pressure. Members who have immature social skills or other problems with social presence need not concern themselves with these unless they are unable to refrain from submitting posts that get them banned from participation.

Netiquette and Guidelines

It is nearly a universal that discussion forums have certain guidelines, expectations, and means of enforcing them. This makes most forums emotionally safe and productive opportunities for gaining support.

Rapid Access to Resources and Topics

By posting URL's (Internet addresses), participants can share additional resources for immediate access by other participants. These resources can be any online resource, or an online reference to a non-online resource. Such resources an include articles, portals (major online topical resources), news, blogs, audio or video presentations, and online services for problems such as time management or learning about medication side effects.
Forums can be divided into topical areas, to guide the nature of the discussion. This can create specialized discussions such as time management, medication, or parenting. Also, discussions are usually threaded. This means that a participants post will be connected to all further discussion and responses related to that post. This makes it possible for participants to choose which "conversations" to participate in or "overhear."

Attendance

With the elimination of geographic and time constraints, attendance can be very good for online forums.

Psychotherapy Groups

Introduction

Structured forms of psychotherapy that uses a group format, cognitive behavioral psychotherapy (CBT), and a highly psychoeducational approach have proven advantageous for certain mental disorders. As of this writing, this kind of approach has been subjected to research when applied to adults with AD/HD, and the research has been supportive, though not sufficiently well-developed. (Aviram, Rhum, Levin, 2001, Hesslinger, et al., 2002, Philipsen, et al., 2007, Toplak, Connors, Shuster, Knezevic, & Parks, 2008, Safren, Otto, Sprich, Winett, Wilens, Biederman, 2005) Research on individual and group psychotherapy has been supportive, but needs to be replicated and expanded upon, and specific types of interventions need to be assessed. Knouse, Cooper-Vince, Sprich, & Safren, (2008) state that, "available data support the use of structured, skills-based psychosocial interventions as a viable treatment for adults with residual symptoms of ADHD." By residual, the authors are referring to symptoms that continue despite the use of medication, because of the populations in the studies that they reviewed.
Challenges to research in this area include comorbidities that commonly occur with AD/HD, the fact that many persons with AD/HD will be one or more of various medications or on no medication, that AD/HD is undergoing significant change in its definition and in our understanding of it, and that persons with AD/HD come into treatment at widely variable levels of denial and self acceptance.
Even when appropriately treated with medication, adults are likely to have a substantial remaining level of symptoms and impairment. (Safren, 2006) This leaves a great need for additional modalities such as psychotherapy, training, and group support.

Elements to Include, Structure

According to Knouse, Cooper-Vince, Sprich, and Safren, (2008), "Common elements across the various treatment packages include psychoeducation, training in concrete skills (e.g., organization and planning strategies) and emphasis on outside practice and maintenance of these strategies in daily life."

Programs researched tended to be time-limited, rather than open-ended, typically around 8-12 weeks in duration. Virta, Vedenpää, Grönroos, Chydenius, Partinen Vataja, Kaski & Iivanainen, (2008) describe such a program and numerous instruments used to assess progress. However, like most studies on this subject, long-term follow up is not included. The number of participants is typically up to 12, as in typical therapy groups.

Safren, Otto, Sprich, Winett, Wilens, Biederman, (2005) have created a book based on a structured psychosocial approach to AD/HD groups. The outline of the structure follows:

MODULE 1: PSYCHOEDUCATION, ORGANIZATION, AND PLANNING
Session 1: Psychoeducation and Introduction to Organization and Planning
Session 2: Involvement of Spouse or Partner
Session 3: Organization of Multiple Tasks
Session 4: Problem Solving and Managing Overwhelming Tasks
Session 5: Organizing Papers

MODULE 2: REDUCING DISTRACTIBILITY
Session 6: Gauging Attention Span and Distractibility Delay
Session 7: Modifying the Environment

MODULE 3: ADAPTIVE THINKING
Session 8: Introduction of a Cognitive Model of Mood
Session 9: Adaptive Thinking
Session 10: Rehearsal and Review of Adaptive Thinking Skills

MODULE 4: ADDITIONAL SKILLS
Session 11: Application to Procrastination
Session 12: Relapse Prevention

Addressing Clinical Issues

The earlier section on Addressing Clinical Challenges and Opportunities covers clinical issues with a special focus on how they relate to group work with this population.
The structured psychoeducational approach such as that described by Safren and colleagues was pioneered in dialectical behavior therapy, initially with persons with borderline personality disorder. (Linehan, 1993) This approach is being applied to many other issues. (Dimeff & Koerner, 2007) One of those is rehabilitative work with severe mental illness through work such as Copeland's W.R.A.P. Manual. (Copeland, 1997) The clinician wishing to use a psychoeducational approach is advised to model the work after that of these authors, but with modifications appropriate to AD/HD such as the modules proposed and used by Safren and colleagues.

Looking to the Future

Additional areas that may be integrated into psychosocial and therapeutic group treatment of adult AD/HD include the following topics that are not adequately researched, but may offer great value.
Lifestyle factors such as running and exercise
Dietary factors and supplements such as omega-3 fatty acids
Methods to improve the effectiveness of sleep
Inclusion of family members in certain formats or at certain times. In informal groups hosted by the author, family members would attend in order to better understand the issues and needs of persons with AD/HD.
Somatic reprocessing of challenging experiences through means such as EMDR and structured body-mind visualization experiences. Clinicians are exploring ways to offer this work in group formats.
Specialized formats designed around needs such as substance abuse recovery, family issues, relationship issues, and employment.

Appendix A: Resources

Support Resources

International list of support groups and other resources: www.ADDers.org
www.ADDResources.org
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD): www.chadd.org/
Robert Yourell's ADD resources page: www.Yourell.com/add
www.ADDitudeMag.com

Online Forums (Discussion) **BOB: check for quality, how bout adda, chadd, google groups

www.ADDForums.com
www.ADHDNews.com Forums: http://www.adhdnews.com/forum/default.asp
www.ADDitudeMag.com/adhdforums/
eHealthForum.com/health/adhd.html
http://ADD.About.com/ Forum: http://forums.about.com/n/pfx/forum.aspx?nav=messages&webtag=ab-add

Legal Issues

ReedMartin.com: Legal issues regarding disability. www.ReedMartin.com
WrightsLaw.com: "Parents, educators, advocates, and attorneys come to Wrightslaw for accurate, reliable information about special education law, education law, and advocacy for children with disabilities." www.WrightsLaw.com

Books, Articles for Clinical Application

Tuckman, A. (2004). Integrative treatment for adult ADHD: A practical, easy-to-use guide for clinicians. Elsevier Ltd.
This is a detailed, readable book with high approval on Amazon.com
Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program therapist guide (Treatments that work). Oxford University Press.
This book is structured into modules for clinical application and has an accompanying client workbook, below.
Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program client workbook (Treatments that work). Oxford University Press.
"ADDA Guiding Principles for Coaching Individuals with Attention Deficit Hyperactivity Disorder represent an attempt to improve the overall care of individuals and their families who are affected by AD/HD." www.ADD.org/articles/coachingguide.html

Citations

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Aviram, R. B.,  Rhum, M., & Levin, F. R. (2001) Psychotherapy of adults with comorbid attention-deficit/hyperactivity disorder and psychoactive substance use disorder. J Psychother Pract Res, 10, 179-186.
Coghill, D., Soutullo, C., d'Aubuisson, C., Preuss, U., Lindback, T., Silverberg, M. & Buitelaar, J. (2008). Impact of attention-deficit/hyperactivity disorder on the patient and family: results from a European survey. Child Adolesc Psychiatry Ment Health, 2(31)
Copeland, M. E. (1997). Wellness recovery action plan. Brattleboro, VT: Peach Press.
de Boo, G. M., Prins, P. J. (2007). Social incompetence in children with ADHD: possible moderators and mediators in social-skills training. Clin Psychol Rev, 27(1), 78-97.
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Dimeff, L. A., & Koerner, K. (Eds.). (2007). Dialectical behavior therapy in clinical practice: Applications across disorders and settings. The Guilford Press.
Friends in Recovery. (1996). The twelve steps: A guide for adults with attention deficit disorder. RPI Publishing
Harvard Mental Health Letter. (2003 ) How effective is Alcoholics Anonymous? 20(6), 7.
Hesslinger, B., et al. (2002) Psychotherapy of attention deficit hyperactivity disorder in adults: A pilot study using a structured skills training program. European Archives of Psychiatry and Clinical Neuroscience, 252, 177-184.
Knouse, L. E., Cooper-Vince, C., Sprich, S, & Safren, S. A. (2008). Recent developments in the psychosocial treatment of adult ADHD. Expert Rev Neurother, 10, 1537-48.
Kyrouz, E. M., Humphreys, K., & Loomis, C. (2002). A Review of Research on the Effectiveness of Self-help Mutual Aid Groups. In White, B. J., Madara, E. J.  American Self-Help Group Clearinghouse Self-Help Group Sourcebook (7th ed.) (71-86). American Self-Help Group Clearinghouse.
Langberg, J. M., Epstein, J. N., & Graham, A. J. (2008). Organizational-skills interventions in the treatment of ADHD. Expert Review of Neurotherapeutics, 8(10), 1549-1561
Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. The Guilford Press.
Moritz, S., Woodward, T. S. (2007). Metacognitive training in schizophrenia: from basic research to knowledge translation and intervention. Curr Opin Psychiatry, 20(6), 619-25.
Philipsen, A.. et al. (2007). Structured group psychotherapy in adults with attention deficit hyperactivity disorder: Results of an open multicentre study. The Journal of Mervous and Mental Disease, 195(12), 1013-1019
Ramsay, J. R. (2007). Current status of cognitive-behavioral therapy as a psychosocial treatment for adult attention-deficit/hyperactivity disorder. Curr Psychiatry Rep, 9(5), 427-33.
Safren, S. A. (2006). Cognitive-behavioral approaches to ADHD treatment in adulthood. Journal of Clinical Psychiatry. [suppl 8], 46-50
Safren, S. A., Otto, M. W., Sprich, S., Winett, C. L., Wilens, T. E., Biederman, J. (2005) Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behav Res Ther, 43(7), 831-42.
Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program therapist guide (Treatments that work). Oxford University Press.
Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program client workbook (Treatments that work). Oxford University Press.
Sagvolden, T., Johansen, E. B., Aase, H., Russell, V. A. (2005). A dynamic developmental theory of attention-deficit/hyperactivity disorder (ADHD) predominantly hyperactive/impulsive and combined subtypes. Behav Brain Sci, 28, (3), 397-419.
Solanto, M. V., Marks, D. J., Mitchell, K. J., Wasserstein, J, & Kofman, M. D. (2008). Development of a new psychosocial treatment for adult ADHD. J Atten Disord, 11(6), 728-36.
Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401.
Tonigan, J. S. (2001). Benefits of alcoholics anonymous attendance. University of New Mexico.
Toplak, M.E., Connors, L., Shuster, J., Knezevic, B., & Parks, S. (2008). Review of cognitive, cognitive-behavioral, and neural-based interventions for Attention-Deficit/Hyperactivity Disorder (ADHD). Clin Psychol Rev, 28(5), 801-23. 
Tuckman, A. (2004). Integrative treatment for adult ADHD: A practical, easy-to-use guide for clinicians. Elsevier Ltd.
Virta, M., Vedenpää, A., Grönroos, N., Chydenius, E., Partinen M., Vataja, R., Kaski M, & Iivanainen, M. (2008). Adults with ADHD benefit from cognitive-behaviorally oriented group rehabilitation: a study of 29 participants. J Atten Disord, 12(3), 218-26.
Vaknin, S. (2008) The Inner Hero Pattern, Originator: Robert A. Yourell. In: The Big Book of NLP Techniques: 200+ Patterns, Methods & Strategies of Neuro Linqjuistic Programming.
von Känel, R. (2008). Psychological distress and cardiovascular risk. Journal of the American College of Cardiology, 52, 2163-64.
Yourell, R. A. (2009). Shimmering for Free Thinkers: Eliminate Stress and Experience Advanced Meditation, Denver: Psych Innovations.