The seed for this book was planted in Catania, Sicily, in 2002 at the Vulcanica Mente (Volcanic Mind) conference during a workshop I conducted with my colleague, collaborator, and friend, Dr. Anthony Rostain. We were presenting an early iteration of our integrated cognitive behavior therapy (CBT) and medical approach to treating adults with attention-deficit/hyperactivity disorder (ADHD). It was this sparsely attended workshop that led me to quip that these early days of our work suffered from “attendance deficit.”
During a question-and-answer session with a small but enthusiastic group of attendees, Dr. Dominic Lam, an expert in CBT for bipolar disorder, asked a very reasonable question: “What is the main cognitive theme in adult ADHD?” He noted that other disorders (e.g., depression, anxiety) that fit within the overarching CBT model display cognitive specificity and distinctive themes in the thoughts of those with a particular diagnosis, and this can guide interventions. Indeed, a tenet of the cognitive component of CBT is that information processing problems play a central role in the vulnerability for, onset of, and persistence of many psychiatric disorders and other forms of emotional distress, even if they do not play a direct etiologic role. At that point in the evolution of CBT for adult ADHD, this question had not yet been addressed by us or our colleagues specializing in the psychosocial treatment of this clinical population. Low self-esteem and maladaptive thinking patterns were observed in adults with ADHD, but no central theme was put forth by anyone. After watching me stumble over observations about the common thinking errors seen in adults with ADHD, Dr. Arthur Freeman, an authority in CBT, leapt to my rescue and noted that CBT and the common distortions offer a model that can be flexibly applied to a variety of disorders. The matter seemed to be settled.
In the intervening years, every workshop I led and every journal article or chapter I authored on CBT for adult ADHD included a disclaimer that ADHD is not the result of negative thinking; it creates life problems that create maladaptive thoughts. Even though CBT approaches have since been well adapted to adult ADHD, as demonstrated in many outcome studies and meta-analyses, the role and relevance of cognitive interventions for adult ADHD has been questioned over the years (Ramsay, 2017b). ADHD can be understood as a performance or implementation problem of difficulties organizing and following through on viable actions and plans (Ramsay & Rostain, 2016a). CBT interventions promote skill-based compensations, coping strategies, and other workarounds for the core difficulties associated with the disorder (e.g., time management, organizational skills, procrastination). There are no “trade secrets” about how to manage ADHD. These behavioral skills, when used, will most definitely improve coping and functioning; and cognitive interventions are helpful as ADHD coexists with mood and anxiety issues and low self-esteem, which are matters within the scope of CBT but that do not necessarily offer distinctive and targeted interventions for ADHD.
So, what is the use of a book-length discussion on the role of thoughts and beliefs in the understanding and treatment of adult ADHD? It seems that the issue was decided by my meager response to Dr. Lamʼs query nearly 2 decades earlier and a circumscribed role for the cognitive domain of CBT for adult ADHD, mainly for cases with coexisting anxiety and depression.
However, the issue is more complex than that. I fully subscribe to the fact that the chief aim of CBT for adult ADHD and its main outcome measure is behavioral; clients can improve functioning and well-being using known coping skills. The cognitive domain, however, provides an essential mediating ligament between the intention and the action in adult ADHD, especially (but not exclusively) for these behavioral coping strategies. Cognitive interventions operate by targeting the implementation deficit that is a defining characteristic of the disorder. It is maladaptive cognitions that often interfere with the deployment of necessary coping strategies for addressing the self-regulatory problems characteristic of ADHD that then set off the cascade of life problems and impairments that necessitate treatment.
A lifetime diagnosis of ADHD is associated with an increased risk for impairments in most domains of life (e.g., school, work, health and well-being, relationships) and, on the basis of recent data, an increased risk of shortened life expectancy. In addition to the day-to-day stress that comes by way of living with ADHD, these domains represent the spheres of life from which one derives a sense of self and belonging. The thoughts, beliefs, and attitudes that develop when clients face these recurring difficulties can affect their identity, perceived opportunities, and sense of effectiveness and hope, all of which stem from the “consistent inconsistency” in the ability to organize behavior across time, which is a recurring theme in the lives of adults with ADHD.
Apart from making the case that the cognitive domain in CBT for adult ADHD is an essential one (though not sufficient) for fostering improvements in clients, a goal of this book is to offer a much-delayed answer to Dr. Lamʼs question and propose that, indeed, there is a central cognitive theme in adult ADHD. This theme relates to a facet of self-efficacy (i.e., self-regulatory efficacy; Bandura, 1997), which is a circumscribed, relatively unsung factor that is a footnote nestled within the broader self-efficacy construct. Impaired self-regulatory efficacy in the cognitions of adults with ADHD sheds light on the cognitive domain as an important mediator of the behavioral strategies by its focus on their implementation, which enables clients to convert intentions into actions, particularly with their proneness for escape–avoidance.
Procrastination is one of the most common problems for adults with ADHD. When recounting examples of missed deadlines or last-minute work binges to beat the clock, adults with ADHD describe knowing full well how to manage such tasks. Maladaptive negative thoughts about a task (or maladaptive positive thoughts) are part of a sequence that gives rise to avoidance despite this know-how, whether it is at the planning stage, how tasks are defined, or the mind-set about the various factors involved in actual engagement and follow-through. These and similar “pivot points” provide high-yield junctures for intervention where the cognitive domain of CBT plays an acutely important role in the use of coping skills for effectively managing and living with ADHD.
This book is written for practicing mental health professionals, clinician–researchers, and clinicians-in-training who are seeking credible and clinically useful approaches that deliver demonstrable improvements in lives of clients with adult ADHD. Related professionals (e.g., educators, advisors, counselors) working with college students with ADHD or ADHD coaches may also find insights and tips helpful to their work. I hope this book is written in a manner such that interested lay readers will also find helpful insights for managing ADHD.
The focus on the cognitive domain of treatment offers a heretofore unique adjunct to and support of the useful coping strategies in existing treatment manuals, client workbooks and guidebooks, and popular self-help approaches. Although this book will deal with adult ADHD through the prism of the cognitive domain, its relevance for behavioral and other interventions is evident throughout the chapters and case examples. The overarching goal is to “see the world through the eyes—and mind-sets—of our clients” to guide and personalize treatment to make it optimally effective.
Each chapter of this book is devoted to the understanding of an aspect of the role of the thoughts and beliefs observed in adults with ADHD. This understanding is used to inform targets for therapeutic interventions, illustrated with case examples. Chapters 1 through 6 offer a Key Clinical Points section that provides useful notes for therapists and models the types of externalized coping reminders provided to adults with ADHD that increase the use of skills outside the session.
Because most therapists have limited knowledge of the ins and outs of ADHD, Chapter 1 provides a therapist-friendly review of the contemporary understanding of ADHD in adulthood. This primer goes beyond diagnostic symptoms and criteria, underscoring ADHD as a neurodevelopmental syndrome of self-dysregulation. Facets of a broader, unified theory of psychology are introduced that are consistent with and reinforce this contemporary view of ADHD, and these facets shed light on other underlying difficulties faced by adults with ADHD. This foundation provides a way for therapists to better understand and discern the manifestation of ADHD in their clientsʼ experiences—to “see” ADHD—and better understand their struggles. Research summaries of the prevalence, persistence, and impairments of ADHD in adulthood underscore the need for treatment. More specifically, CBT for adult ADHD is better understood as targeting and operating at the level of the functional impairments than as directly treating the core symptoms.
Chapter 2 outlines the research relevant to CBT for adult ADHD, including cognitions and beliefs typically encountered in clinical practice. The chapter starts with a review of evidence-supported medical and psychosocial treatments, which are focused on outcome studies of CBT for adult ADHD. Recent research on cognitive distortions and maladaptive schemas in samples of adults with ADHD that support a CBT model of adult ADHD and its constituent interventions are then reviewed.
The overarching CBT model for the conceptualization and treatment of adult ADHD is presented in Chapter 3. The CBT case conceptualization is discussed first, which itself is a clinically informed synopsis of the overarching CBT model of psychotherapy. The discussion of the adaptation of this model to adult ADHD, particularly the cognitive domain, is achieved through the introduction of the contemporary generic cognitive model of emotional disorders. This introduction highlights recent modifications to the generic model pertinent to (though not mentioning) ADHD and clarification of points where CBT specifically designed for adult ADHD has been adapted to the unique features of this clinical population. This chapter will draw on the aforementioned models and research to introduce the ways in which cognitions and beliefs are clinically relevant in the psychosocial treatment of adult ADHD, including the proposal of self-regulatory efficacy as the central cognitive theme followed by an outline of the premises about adult ADHD that inform a set of premises about psychosocial treatment of adult ADHD.
Chapter 4 takes this adapted CBT model and self-regulatory efficacy cognitive theme and reviews the cognitive interventions within CBT for adult ADHD. This chapter uses classic cognitive interventions that are tailored for use with adults with ADHD. In addition to assessing and modifying the cognitive patterns and distortions of adults with ADHD, the role of these approaches to frame/reframe tasks, promote implementation and follow-through on behaviors, and deal with maladaptive positive thoughts are among the clinical topics.
Building on this, Chapter 5 illustrates these cognitive interventions “in action” to provide therapists with frameworks for helping clients who have difficulties organizing behavior over time and deploying tried-and-true coping strategies that improve functioning. CBT for adult ADHD can be considered extended release CBT or implementation-focused insofar as the goal is to make interventions portable or “sticky”; the aim is to increase the use of these strategies by clients outside the consulting room at the time and place when they are needed most. Topics in this chapter include helping clients address the common presenting issues of procrastination, time management problems, and disorganization as well as dealing with ambivalence about starting treatment, handling setbacks, and other essential coping issues for adults with ADHD.
Chapter 6 covers several miscellaneous “special case” clinical issues relevant for therapists. Topics include managing comorbid mood and anxiety problems (and suicidality), excessive technology use, phase of life problems for young adults and older adults with ADHD, attitudes about medications, and others. The thoughts and beliefs of loved ones and other stakeholders in the lives of adults with ADHD are also reviewed, including reactions by therapists when working with adults with ADHD.
Although case examples are used to illustrate interventions and principles throughout the book, Chapter 7 provides three extended case examples to give readers a sense of how everything fits together.1 Common issues are discussed related to procrastination, implementation of coping skills, emotion regulation and comorbidities (including substance use), and automatic thoughts and core beliefs, among others, and therapist commentary is interspersed throughout the case examples.
In addition to the various sources cited throughout the book, the reference list provides interested readers with manuals and client guidebooks for CBT for adult ADHD, which are denoted with an asterisk. The Appendix provides a list of additional credible resources, including client- and therapist-oriented websites and organizations.
ADHD is a uniquely and disturbingly mystifying condition for those affected by it. It is not a knowledge deficit. Advising clients struggling with procrastination to “start earlier” is like telling people with depression to “cheer up.” ADHD is an implementation problem—a problem efficiently organizing and carrying out viable actions toward desired, viable, but deferred goals. An insidious aspect of ADHD is that the very problems for which clients seek help are the ones that could undermine psychosocial treatment—poor follow-through on coping skills and use of the skills outside the consulting room.
The model reviewed in this book is designed to help adults with ADHD define and navigate small, achievable pivot points for taking small behavioral steps with which to implement their skills and plans. This model also provides a template with which they can understand their setbacks in behavioral terms (“I did not break down that task into small enough steps”) rather than in characterological terms (“Iʼm a failure”). This template turns coping with ADHD into something actionable clients can “do.”
I hope that practicing clinicians who read this book will come away with a similarly useful template with which to “see” the challenges faced by their clients with adult ADHD, “hear” the inner self-talk of cognitions and beliefs, and collaborate with clients to establish specific therapeutic skills and strategies that they can “do” to good effect in their lives.2 These approaches, often used in combination with coping tools and strategies developed and disseminated by many professionals in the specialty of adult ADHD, hold the promise of helping clients achieve newfound improvements and outlooks about their worlds, their futures, and themselves.