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The Hidden Disorder: A Clinician’s Guide to Attention Deficit Hyperactivity Disorder in Adults
By Robert Resnick. American Psychological Association, 2000, 153 pages, $27.97 (Amazon.com).
The Hidden Disorder: A Clinician’s Guide to Attention Deficit Hyperactivity Disorder in Adults by Robert Resnick is a must-read for clinicians who work with adults. This book provides a comprehensive look at ADHD including the history of the disorder, present diagnostic criteria, and treatment interventions. It emphasizes the importance of assessing for ADHD in every evaluation and consultation conducted with an adult patient.
Resnick uses a developmental perspective to address ADHD throughout the lifespan. He maintains that ADHD is not a disorder restricted to children, but one that affects vast numbers of adults. He expands upon the two core symptoms presently offered by the DSM-IV and conceptualizes ADHD as consisting of four core symptoms: inattention, impulsivity (with or without), hyperactivity, and distractibility. Focusing on adult presentations of the four core symptoms, Resnick provides relevant examples of how adult symptoms may differ from childhood symptoms. For example, he maintains that attention difficulties may not be as evident in adulthood. Adult patients are no longer in school and have choices in the workplace. This allows them more choices about whether or not to engage in activities that require sustained attention. Resnick posits that an adult with ADHD would be less likely to engage is such activities. He provides case vignettes to illustrate examples of adult presentations of the four symptoms. In addition, he identifies affective lability and learning disabilities as additional considerations in the evaluation of an adult with ADHD. He offers additional examples of ADHD presentations in adults within marital relationships, the workplace, the military, and in recreation and leisure activities.
The book explores diagnostic criteria as offered by the DSM-IV, Hallowell and Ratey’s (1994) diagnostic criteria for ADD in adults, and the Utah criteria for ADHD in adults (Wender, 1995). Resnick notes that in some cases, diagnoses may have been missed in childhood, depending on symptom presentation and setting. He explores several mitigating factors that contribute to missed diagnoses in childhood and explains that adults do not “grow out” of ADHD. The book places a lot of emphasis, through an exploration of symptoms and case vignettes, on the importance of differential diagnosis and comorbidity. Specifically, Resnick addresses depression, anxiety, obsessive-compulsive and anxiety disorders, antisocial personality, bipolar disorder, substance abuse, learning disabilities, differences in neurobiology between the genders, and other behavioral disorders.
The book emphasizes the importance of assessment for ADHD in adult patients. Core considerations of assessment interventions such as observation, as well as obtaining a retrospective history, work history, and substance use history are explored. Resnick further addresses current trends in psychological testing, rating scales, and computerized tests of attention. In today’s day and age of mental health practice, medical management is closely linked to diagnosis. Resnick considers medical management issues such as referral and reimbursement. He provides practical information, such as billing codes, to help clinicians effectively identify and treat adults with ADHD.
The book offers an assortment of treatment interventions, including short-term and long-term options. Short-term interventions include psychoeducation, individual psychotherapy, bibliotherapy, and pharmacological considerations. Resnick suggests that the incorporation of significant others may help treatment in that family members often do not understand the nature of the disorder, and by extension, the reasons behind the patient’s problematic behaviors. He explores therapeutic considerations such as monitoring, resistance, and systems issues (e.g. between physician and psychotherapist). Long-term interventions address the very real possibility that adults with ADHD frequently need intermittent interventions as they make developmental changes over the lifespan.
One of the major strengths of this book is the comprehensiveness of the material related specifically to adult ADHD. While much has been written about ADHD in childhood, very little literature exists in the way of ADHD in adults. Resnick does not simply attempt to re-work existing childhood criteria so that they fit adulthood criteria. Rather, he expands on existing information, such as the commonly used DSM-IV diagnostic criteria, offering two additional core symptoms. He frequently uses real-life examples to demonstrate how ADHD manifests itself (differently) in adult patients. Psychotherapists should be able to very effectively assign specific sections of the book to clients to help them better understand the disorder and discuss these sections in subsequent treatment sessions.
A potential limitation of this book is high level of comprehension needed to sufficiently understand the information contained therein. While a psychotherapist could easily use this book to educate him or herself, the same psychotherapist might have difficulty using this book as a bibliotherapy adjunct. It seems to require a higher reading level than the average patient could be expected to master. So, some attention to this and assistance from the psychotherapist to ensure patients’ understanding may be required. The book also includes an appendix of adult ADHD resources, as well as a list of national organizations and support groups, that could easily be photocopied and distributed to patients as adjunctive bibliotherapy resources. He also includes a reference list of publications and resource materials for professionals.
I would strongly recommend this book as a resource for any psychotherapist working with adult patients. Resnick’s emphasis on the importance of assessing for ADHD in every evaluation and consultation is well taken. Diagnostic considerations, including comorbid disorders, are concisely, yet thoroughly addressed. This may help the psychotherapist to educate him or herself, as well as patients about the clinical presentation of ADHD in adulthood.