This Weeks Post From Diagnosis and DSM-5
Both parts of this question bring countertransference for me to the max. For any prospective counseling peers who have completed one or more classes with me in the past, some of what I write will seem like “old hat.” I’ve focused on autism spectrum disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) in many forums with a deep-felt emotion and burning desire to learn. As an educator, I thought I had grasped learning theory and discipline for years. I was living deceived.
That was before I married late in life, and God blessed my wife and me with a son whose mental health history would be full of surprises. At four, he was diagnosed with sensory deprivation. Hence, weighted blankets, bouncy balls to sit on, etc. At seven, professionals scored him on the ADDES-4 (Attention Deficit Disorder Evaluation Scale – Fourth Edition), and he scored out two standard deviations from “normal” and began medication for ADHD. His standardized test scores jumped.
He had attended a small Christian school in our community but entered public middle school – and my class and hallway in sixth grade. I was immediately concerned with his lack of interaction with most of his peers. At the same time, a knowledgeable speech teacher confronted his mother and me, encouraging us to have him evaluated for autism. His testing included the Autism Diagnostic Observation Schedule (ADOS), where he earned a score similar to what had been called Aspergers before the DSM-5 but now integrated into the autism spectrum.
What I wasn’t ready for – and what the question asked – would be his post-high school travails, both with autism and with ADHD. Supposedly our school system had transition services to meet requirements. It was just that - for the system to say they had met requirements. What’s more, the junior college where he enrolled insisted they provided services for learning and socially disabled kids of all kinds.
We found that our son had fallen off the cliff upon high school graduation. First of all, I recently discovered that while middle and high school specialists and resource room personnel encourage parents, praising the child, and talking about the child’s progress, some manifestations of the child/adolescent’s disorder don’t manifest themselves before young adulthood. That youngster may have increasing needs, not less. The years after high school have been the most trying for his mother and me.
Second, his long-time peers accepted some oddities, as “Oh, that is just him.” Now potential bosses and friend interests, both men and women, ignore him, or at least they do to his perception. What’s more, he is uncomfortable with them because he doesn’t understand why they think he ought to dress less weirdly, shower more frequently, etc.
Third, as we live in a rural state, professionals that understand an ASD/ADHD comorbidity are rare. While he’s had some excellent general licensed practical counselors, one failed to recognize his ASD and concentrated on the ADHD, and the other still struggles with his lack of social graces and seeming ingratitude when he is working with emotions or perceives some personal need that simply must be more important than anyone else’s need.
Fourth, the junior college’s assertion that they stood ready to help came with a caveat: all he has to do is come get it. They might as well ask him to fly to the moon. Some months ago, he gained employment with an excellent local firm. We gave him a canceled check to give to the business office to implement direct deposit of his checks. He refused to do it due to dealing with increasing numbers of people. Eventually, he quit working because he said the anxiety of an open floor (up to 100 people working in the same room) was overwhelming.
In closing, my wife and I have done enough peer-reviewed research through the Chadron Library to know that what we face is not unique. 50 – 75% of high functioning autistic young adults are unemployed (Smith et al.,2015). A majority are living with a parent or other adult figure. Like our son, they can fail to read cues from possible romantic interests properly. Further, the cues they read correctly are often from individuals similar to themselves, which can amplify the needs of both individuals.
Transitioning to the second question, Sokolova et al. state that “recent research recognizes considerable clinical, genetic, and neuropsychological overlap between ASD and ADHD, and within the DSM-5, ADHD can now be diagnosed in conjunction with ASD” (p. 1595, 2017). As a result, an individual with such a comorbidity needs strategies for treatment with two very debilitating disorders.
According to Kress and Paylo, Cognitive Behavior (CBT) “helps [ADHD clients] develop the skills necessary to effectively navigate its accompanying symptoms.” (p. 435, 2019). In treating ADHD, CBT focuses on enhancing attention span, memory, impulse control, problem-solving skills, emotion regulation, social skills, and organizational skills. An interesting side-note for me is that this description could easily be applied to autism, as we described above. In either case, CBT counselors help clients apply these skills in various life situations.
The three most common struggles for ADHD clients are organization, time management, and planning. They must also learn self-talk strategies to help them stay focused. As an aside, I think I have used this strategy for years, and didn’t realize what I was doing.
In any event, disorganization, always being late (or occasionally early), going through life with no sense of planning can lead to a very adverse self-view. Therefore, the CBT counselor will work in several areas. These include:
· Increasing organization and planning skills by a documentation system, deconstructing major assignments, and creating action plans
· Reducing distractibility by increasing awareness of the need for a break, dividing larger tasks into chunks, using timers and alarms, and writing down directions as they occur.
· Increasing problem-solving skills by learning techniques to aid in deconstructing the task.
· Learning and applying cognitive restructuring techniques by identifying and challenging self-critical thoughts and beliefs
· Reducing procrastination by applying problem-solving techniques in problem areas.
· Improving communication skills by implementing active listening, learning to intercept and interpret the social cues of others
· Learning and applying anger and frustration management techniques, including learning stress reduction strategies and engaging others energetically, not obnoxiously. (Kress and Paylo, 2019)
What I’ve written about CBT and ADHD could help many young people in the public school setting. However, as a counselor friend states cynically, “Students are not treated till they bother adults.” Therefore, many ADHD and ASD young people miss the chance to participate in treatment the text describes as a tenet of CBT for ADHD. Hopefully the future will allow the expansion of this kind of therapy for both neurodevelopmental groups.
Kress, V. E., & Paylo, M. J. (2019). Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment. Pearson.
Smith, M. J., Fleming, M. F., Wright, M. A., Losh, M., Humm, L. B., Olsen, D., & Bell, M. D. (2015). Brief report: Vocational outcomes for young adults with autism spectrum disorders at six months after virtual reality job interview training. Journal of Autism and Developmental Disorders, 45(10), 3364–3369. https://doi.org/10.1007/s10803-015-2470-1
Sokolova, E., Oerlemans, A. M., Rommelse, N. N., Groot, P., Hartman, C. A., Glennon, J. C., Claassen, T., Heskes, T., & Buitelaar, J. K. (2017). A causal and mediation analysis of the comorbidity between attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Journal of Autism and Developmental Disorders, 47(6), 1595–1604. https://doi.org/10.1007/s10803-017-3083-7
