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Section 25
Case Study: Career-Focused ADHD Assessment

Question 25 | Test | Table of Contents

Paul was a 37-year-old attorney who called for an appointment after he was informed that he would not be considered for a promotion to partner in the firm that had employed him for several years. Divorced after a brief marriage in his late twenties, he was now in a serious relationship with a woman he hoped to marry. Paul had struggled, working many hours on evenings and weekends, in a failed attempt to keep up with his workload. Although the quality of his writing was good, his output was far below what was expected. Paul reported increasing symptoms of depression. His sleep was restless, and he had great difficulty falling asleep at night. He felt discouraged and had little hope that he would find another good job if he were not promoted to partner in his current firm. Paul’s girlfriend, a teacher, had suggested to him that he might have undiagnosed ADHD. She had worked with many children who had ADHD and noticed similar patterns in Paul, including forgetfulness, messiness, difficulty getting started on tasks, and a struggle to meet deadlines. As a boy, Paul recounted, he was considered a bright student but struggled with reading and writing. What he lacked in ability, Paul had tried to make up for with effort. For example, in reaction to his learning difficulties he decided to major in English in college, with the belief that if he tried hard enough long enough, he could overcome his reading and writing problems. In fact, this pattern seemed to have been his standard approach to challenges—full tilt ahead as a battering ram, trying to knock down the wall instead of looking for the door.

Career-Focused ADHD Assessment
Because Paul was strongly considering a change of career after his recent disappointment, I undertook a full evaluation. I began with an extended clinical interview to gather information about family history, educational and vocational history, and psychiatric history. In addition to taking neuropsychological tests, Paul completed the MBTI, the Strong Vocational Interest Inventory, and self-assessment inventories related to ADHD problems in the workplace (see Nadeau, 1996). Neuropsychological testing results indicated that Paul had a full-scale IQ above 130. His vocabulary, general information, and abstract reasoning were all excellent despite his struggles with reading and writing. His test performance also demonstrated strong visual/spatial and mathematical ability, although the examiner noted that it was often necessary to repeat instructions or questions. Educational test results indicated that his reading and writing rates were well below expectation. Handwriting was laborious and nearly illegible. Test results suggested difficulty with working memory, particular verbal working memory, as well as processing speed. A computerized test of attention showed borderline problems with sustained attention. It was observed that he talked under his breath during this test, apparently as a means of maintaining focus. It is not unusual for an intelligent, motivated adult who has ADHD to score in the normal or borderline range on a computerized test of attention. Paul’s history as well as his responses to the Brown Attention Deficit Disorder Scale (BADHDS) were consistent with a diagnosis of ADHD. MBTI results suggested that Paul’s personality was ENFJ—an extroverted, people-oriented individual with a preference for abstract ideas over the practical and tangible. Paul’s responses to the Strong Interest Inventory suggested that his choice of career in the law was very consistent with his interests.

Course of Treatment
Assessment Feedback. The first order of business was to spend several sessions giving Paul feedback about the results of his career/ADHD assessment and educating him about ADHD. I explained to Paul that testing showed he was very bright and that his intelligence and hard work had helped him to compensate for both a language-based learning disability and a moderate level of ADHD. I shared my impression that his depression was a reaction to recent events in his life and would probably remit as he gained a better understanding of himself and charted a course for his future that was better matched to his strengths and personality. I also explained to Paul that testing did not suggest that he had made a poor career choice. He had excellent verbal reasoning ability and good intelligence. He showed a strong interest in people, a desire to be helpful to people, and an ability to get along with them. His areas of weakness, however, had led to his downfall in his most recent job. Reading and writing speed, though above average, were not high enough to allow him easily to manage a legal career that primarily involved writing long, complicated briefs. And his relative weakness in processing speed suggested that he was not a good match for a high-pressure law firm.

Education/Reframing. A bright, highly educated man, Paul was interested in learning about ADHD. I provided an overview of ADHD, including a discussion of genetic and brain chemical characteristics and recommended a reading list including my book on workplace issues. This educational process helped Paul to feel better informed and ready to take steps to manage his condition. A full course of treatment was laid out for Paul. Scoring as an N on the MBTI, he liked to see the big picture, to have a theoretical overview of how we would address his concerns. We discussed using stimulant medication, learning compensatory techniques, and making environmental changes as different components of treatment. I referred him to an adult ADHD support group as well.

Referral for Medication Evaluation. Paul preferred to begin his treatment without using medication. The choice of using medication was Paul’s to make; however, the therapist continued gently to encourage a trial of medication. Paul had much work ahead of him—important decisions to make, many tasks to complete—as he charted a course for his future career. I shared my belief that these tasks would be completed more easily and efficiently with the benefit of stimulant medication. Paul attended an adult ADHD support group, in which he listened to other adults talk about their experiences with medication. Although some had encountered problems, most felt that medication had clearly helped them. Paul returned to his next therapy session ready to schedule an appointment for a medication consultation.

Treating the Whole Person. Initially, Paul assumed that he should discuss only ADHD and career issues. I encouraged him to talk about all aspects of his life, explaining that his ADHD did not define him. ADHD was only one factor that needed to be considered as Paul worked to feel and function better. With encouragement, Paul began to talk about other aspects of his life. Paul’s former wife had resented his long work hours and had interpreted his forgetfulness as a sign that she was not important to him. Their brief marriage ended when his wife left, deciding to move back near her family. Gayle, whom he had been dating for the past year, was much more supportive and patient. She did not like his long work hours either, but she seemed to understand his struggles. Paul’s former wife had liked the fact that he worked for one of the top law firms in town. Gayle, on the other hand, encouraged him to find a different job. "No job is worth killing yourself for," she would tell him. Paul loved Gayle but was afraid of experiencing another failure. His parents’ marriage had not lasted, and his own marriage had ended in divorce after only 3 years. Besides, he worried, Gayle might be supportive now, but she would not want to stick around if he could not get his act together. Paul talked about the fierce self-reliance that he had developed as a boy. His father had mocked and teased him then about his difficulties in school. Paul’s reaction had been an angry determination to prove his father wrong. After his parents separated when Paul was 12, his mother’s hard work to support the two of them increased his determination to succeed. Paul worked his way through state college, intentionally choosing the most challenging major, English, believing that he could overcome his difficulties through sheer determination.

Charting a Career Course. Paul and I explored his work history, during college years and afterward, before he decided to go to law school, evaluating which jobs had gone well and which had been negative experiences. A profile began to emerge. Consistent with his E (extroverted) personality, Paul preferred the jobs that allowed interaction with people. Paperwork had always been his downfall—a very typical workplace issue for adults who have ADHD—and he had been sensitive and overreactive to supervisors who were even slightly critical or abrasive (who were reminiscent of his critical, abrasive father). Together, we began putting together the career puzzle. Interest and intelligence testing both suggested that he had not made a poor career choice. He had the ability to practice law, but clearly he should not have sought legal work that predominantly involved writing. His desire to be helpful and his people skills suggested that family law might be a good choice. His ability to see situations from others’ points of view suggested that he might make an excellent mediator. Paul’s extroversion also meant that he would have less difficulty than other attorneys in developing his own practice. His MBTI profile suggested that he would be more motivated by having work that was helpful to others and that was intellectually stimulating than by earning a top income. Paul was in an excellent position to take a risk in starting his own practice. He was unmarried, had no children, and had no mortgage to pay. By living frugally, he could make his 6-month severance package last a year, a year in which he could set up a small office and begin to get referrals. Importantly, we talked about his areas of weakness. He needed to think about finding others who had strengths in his areas of weakness—perhaps a part-time, highly organized office manager. Paul would be well matched with a more introverted, detail-oriented law partner who could focus on the business aspects of the practice while Paul focused on development of a referral base.

Outcome and Prognosis. Paul responded well to stimulant medication. He felt more focused and organized at work, to the point that he even flirted with the notion of finding similar work with another firm. Discussing this idea in therapy, Paul was able to recognize his old pattern: using his battering ram approach instead of looking for the door. He began to appreciate his strengths and to understand that success would be reached through emphasizing those rather than storming the ramparts of his disabilities. At my suggestion, Paul had researched information on mediation and signed up for a training course. Unlike his experience with legal research and writing, with mediation he was a natural. Chris, the attorney who taught the course, encouraged him to consider developing a mediation practice. Three months after beginning his course of treatment, Paul left the law practice. His relationship with Gayle continued to be strong and, as he began to regain confidence, he talked more openly of moving in with Gayle and—who knows—maybe even marrying again. Much of his therapy focused on letting go of the lifelong struggle to "prove himself" by doing things the hard way. Away from the constant pressure and discouragement of the law firm, Paul began to appreciate better his strengths and to focus less on his struggles. The attorney who taught the mediation course invited Paul to pick up some part-time legal work at his law office while he focused on how to begin to establish his own practice.

Discussion
What has been described here is different from traditional psychotherapy, but also different from traditional career counseling. As a psychologist, trained to understand test results, as a psychotherapist trained to address psychological considerations (regarding parents, childhood struggles, relationships, coping styles, and self-concept), and with the benefit of experience, I was able to help Paul in a way that probably would not have been possible had he received more traditional psychotherapy or career counseling. In a 16- to 18-week period, this multimodal treatment helped Paul to reframe his ADHD more constructively, to benefit from stimulant medication, to recognize and appreciate his strengths, to understand better his need for supports and complementary strengths in others, and to feel less fearful and defensive in his relationship with Gayle. Paul had immersed himself in mediation, an area of law better suited to him, and had received positive feedback that further reinforced confidence in his new choices. With this growing confidence and optimism, Paul was able to respond to Chris’s overture in a constructive fashion. At this juncture, Paul still has far to go to create a suitable, stable work environment for himself. However, the multifaceted treatment outlined in this article has put him in a position in which he is more likely to succeed. He has a supportive relationship in which he is beginning to have faith, he has received positive overtures from the attorney who teaches his mediation class, and he has ongoing support and guidance from his therapist as he considers his options.

Summary
As illustrated in this case, standard career counseling provided by a career counselor would probably have been inadequate for Paul in determining his future course of action. Paul’s progress and ultimate career direction required extensive analysis of cognitive and psychological issues as well as a detailed knowledge of the multiple workplace considerations. Although no single mental health profession teaches all of the skills and knowledge that must be brought to bear on career guidance and counseling with an individual who has ADHD, the psychologist who has competencies in psychotherapy, testing, and measurements is probably best equipped to take on this fascinating and challenging task.
- Nadeau, Kathleen G.; Career Choices and Workplace Challenges for Individual with ADHD; Journal of Clinical Psychology; May 2005; Vol. 61 Issue 5, p549.

Treatment of adult ADHD: A Clinical Perspective

- Geffen, J., & Forster, K. (2017). Treatment of adult ADHD: A clinical perspective. Therapeutic Advances in Psychopharmacology, 8(1), 25-32. doi:10.1177/2045125317734977

Personal Reflection Exercise #11
The preceding section contained information about career-focused ADHD assessment.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Work-MAP Telehealth Metacognitive Work-Performance
Intervention for Adults With ADHD: Randomized Controlled Trial

- Grinblat, N., & Rosenblum, S. (2023). Work-MAP Telehealth Metacognitive Work-Performance Intervention for Adults With ADHD: Randomized Controlled Trial. OTJR : occupation, participation and health, 43(3), 435–445. https://doi.org/10.1177/15394492231159902


Peer-Reviewed Journal Article Reference:
Bottini, S., Polizzi, C. P., Vizgaitis, A., Ellenberg, S., & Krantweiss, A. R. (2019). When measures diverge: The intersection of psychometric instruments and clinical judgment in multimodal adult attention-deficit/hyperactivity disorder assessment. Professional Psychology: Research and Practice, 50(6), 353–363.

Courrégé, S. C., Skeel, R. L., Feder, A. H., & Boress, K. S. (2019). The ADHD Symptom Infrequency Scale (ASIS): A novel measure designed to detect adult ADHD simulators. Psychological Assessment, 31(7), 851–860.

Walther, C. A. P., Pedersen, S. L., Gnagy, E., Pelham, W. E., & Molina, B. S. G. (2019). Specificity of expectancies prospectively predicting alcohol and marijuana use in adulthood in the Pittsburgh ADHD longitudinal study. Psychology of Addictive Behaviors, 33(2), 117–127.

QUESTION 25
Paul’s progress and ultimate career direction required what types of extensive analysis? To select and enter your answer go to Test.

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