CBT for Adult ADHD: Getting Patients to Do What They Know They Need to Do

While medications are considered a first-line treatment for adult attention-deficit/hyperactivity disorder (ADHD), several sessions at this weekend’s annual meeting of the American Professional Society of ADHD and Related Disorders (APSARD) centered around the topic "Outside the Pill Bottle: Assessment and Management of Adult ADHD."

One of those sessions, "Intentions Into Actions: CBT for Adult ADHD," reviewed a model for understanding and treating adult ADHD with cognitive-behavioral therapy (CBT), which has emerged as the second evidence-supported treatment for adult ADHD.

“I know what I need to do, but I just don’t do it.” According to psychologist J. Russell Ramsay, PhD, he has heard that statement from most adults with ADHD seeking CBT to help overcome challenges with functioning in daily life and in various roles. Ramsay is co-director and co-founder of the University of Pennsylvania Adult ADHD Treatment and Research Program and an associate professor of clinical psychology in psychiatry at the Perelman School of Medicine at the University of Pennsylvania.

CBT is aimed at getting adults to follow through on recommendations and other coping strategies for what they are supposed to be doing to improve daily functioning.

Telling ADHD patients to just use planners is not useful, Ramsay indicated. "We’re talking about implementation," he said. "That’s where the rubber meets the road.”

There are 4 CBT intervention categories for adults with ADHD: 


• Cognitive modification (changing how patients think about things)
• Behavioral modification and coping skills (doing things differently, essentially an outcome measure for treatment effectiveness)
• Acceptance, mindfulness, persistence (this could include emotional regulation)
• Implementation strategies.

Planners or relationship counseling are a way of targeting what he called “pain points” in the real world.

Conceptually, he said, patients with ADHD experience symptoms along a continuum of severity and impact. ADHD causes functional difficulties across a wide range of settings and situations with many variations, and may include other emotional and learning issues.

According to Ramsay, “ADHD symptoms influence experience and performance in various life roles and endeavors, with effects on sense of self, identity, and efficacy. There is an ongoing, reciprocal interaction between an individual and their contexts and relationships that can magnify and/or attenuate difficulties, coping strengths, and sense of belongingness and social capital.”

ADHD alters “information processing in the form of thoughts and beliefs, as well as concurrent emotional and behavioral experiences, that affect how one acts on and reacts to various contexts and roles and relationships.”

Ramsay called ADHD an implementation problem in that patients have difficulties performing the necessary skills and strategies needed to effectively manage a task, endeavor, role, or situation; it is not from a lack of knowledge of what needs to be done or a lack of ability to perform.

Patients have self-regulation problems that involve difficulties organizing, initiating, and sustaining actions over time in order to achieve a future-focused outcome that is personally rewarding and desired. This may lead to:

• Procrastination
• Poor motivation for behavior (both initiating and sustaining over time)
• Poor task endurance
• Difficulties sustaining efforts across time, working towards a deferred reward
• Tendency to discount deferred rewards, which are experienced as less salient than proximal rewards
• Corresponding difficulties with initiating and sustaining attention, disorganization, poor working memory, and emotional dysregulation, which punctuate experience and efforts
• Difficulties executing known, effective coping strategies for managing these problem areas.

Ramsay said that some might like to say, "well then, isn’t it true that everyone has ADHD?" In other words, is ADHD a myth? The answer is no, he said, because ADHD depends on the magnitude, frequency, and level of impairment.

For some patients, ADHD difficulties magnify and amplify coexisting psychiatric and learning disorders, as well as other life stressors.

Ramsay also presented intervention strategies targeting behavior, emotions, and implementation of how CBT might play out in clinical practice with a patient, using several examples from lessons learned from working with those who suffer from what he called “procrastivity.”

He defined procrastivity as avoiding a higher-priority task by engaging in a lower-priority, less time-urgent (but productive) endeavor that is ultimately self-defeating—such as mowing the lawn when you should really be doing your taxes, or avoiding an overgrown lawn and browsing the Internet for vague research tasks instead.

APSARD 2018 met in Washington, DC, from January 12-14.