J: I’m not a good husband or a good father. I’m incompetent when it comes to handling things that are important.
As we can see, though procrastination is a common problem for ADHD adults, John’s avoidant behaviors and incompetency beliefs reciprocally compound each other, result- ing in his continued delay in dealing with his taxes and his negative view of himself as a poor provider for his family. Thus, behavioral experiments devoted to reducing procras- tination and handling problems in a timely manner represent not only coping skills for ADHD, but also experiential exercises with which to help John challenge his negative beliefs. Additional cognitive interventions can help John to identify positive ways he fulfills his roles as father and husband that have nothing to do with whether or not he procrastinates.
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For many adults with ADHD, it only takes two or three questions before reaching the underlying negative belief. As we mentioned earlier, individuals with mild, uncompli- cated cases of ADHD may not exhibit maladaptive schema and CBT for these individu- als helps them to learn to cope better in their current environments, such as improving their organizational skills at work. In other cases, the various cognitive and behavioral interventions hopefully provide ways to modify the belief system. Managing the effects of ADHD and consistently implementing effective coping strategies remains central to CBT for adult ADHD. However, clinicians must pay attention to how the underlying belief systems, that is, maladaptive schema, interfere with adult ADHD patients’ engage- ment in the change process, and provoke intense reactions to difficulties encountered in this process.
The targets of cognitive interventions are the various thoughts and rationalizations that interfere with coping with the effects of ADHD and executive dysfunction. Cogni- tive interventions have played a heretofore underappreciated role in emotional regula- tion and self-motivation in efforts to manage ADHD. The ultimate goal of the cognitive interventions is to foster resilient outlooks that support the persistent use of coping strategies for ADHD even in the face of ongoing symptoms and challenges.
Despite its emphasis on exposure to various situations and testing out one’s assump- tions, CBT is not often considered an experiential form of psychotherapy. However, CBT for adult ADHD emphasizes the application of various strategies with which to manage the effects of ADHD on one’s life. Therefore, the behavioral interventions discussed in the next section are paramount. It is the consistent use of coping strategies to improve functioning that is the ultimate measure of the effectiveness of treatment.
Behavioral Interventions
The aim of behavioral interventions is to help patients form new behavior patterns, gain new coping skills, and improve outcomes in domains of their lives that heretofore have proven difficult to manage. The dual purpose is to improve functioning and, conse- quently, to gain novel experiences from which to revise one’s attitudes and outlooks so as to sustain adaptive functioning.
There are several skill domains that are standard fare for most psychosocial treatment programs for adults with ADHD, such as time management, organization, and other manifestations of the executive functions. There are many easily accessible resources providing useful information about specific coping skills and ways to manage adult ADHD. However, adults with ADHD describe knowing what they need to do but having difficulty actually doing so, which is the biggest challenge to employing behavioral interventions.
One of the important behavioral principles in CBT for adult ADHD is ensuring that a targeted behavior is being sufficiently reinforced to increase its frequency. This is a basic behavioral principle but it is important to emphasize for adults with ADHD because they often experience delay aversion and reward deficiencies, making reinforce- ment difficult (Sonuga-Barke, 2011). Typically this involves applying positive reinforce- ment to a particular coping strategy, such as watching a football game as a reward for completing yard work. The use of linking stimuli can be used to help someone engage in a challenging task, such as listening to enjoyable music while doing housework.
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Similarly, it is very helpful to develop adaptive behavioral routines to improve initiation and follow through on tasks, and to decrease any potential interference from emotional frustration associated with disorganization.
In working with adults with ADHD, we discuss the behavioral scripts they have devel- oped that either enable or hinder follow-through on desired plans. By identifying the existing scripts that interfere with their intentions, alternative behavioral scripts can be developed. For example, Tom said that he often left work in the afternoon with plans for exercising and for researching potential certification programs that would help him get promoted at work. At the end of his shift, his plans for when he got home seemed rea- sonable and he felt motivated. However, by the time he reached his apartment, his motivation had waned and he invariably got distracted by a variety of low priority tasks that allowed him to “unwind” but that were unfulfilling and ultimately undermined his best-laid plans.
More specifically, Tom and his therapist laid out his existing “arriving home” behav- ioral script. They figured out that arriving home after work was associated with feeling tired and the attitude of “Now I can relax.” The initial behavior of sitting on the couch and turning on the television was associated with being sedentary, accentuating the fact he was somewhat tired after a full day at work, and reinforcing that it was pleasant to
“unwind and ‘veg out’” for a while. Tom also had difficulties disengaging from the televi- sion, where he was always able to find programs or video games that were immediately more compelling than any of the plans he made on his way home. After a while of play- ing out this script, he determined that he was “not in the mood” to exercise or to search for a job. He comforted himself with the thought that he would perform these tasks tomorrow. Those rationalizations were not a plan but were rather part of the unproduc- tive behavioral script.
It was pointed out to Tom that there was nothing unethical, immoral, or illegal about how he spent his time after work. However, Tom agreed that this habitual routine, though relaxing, was not fulfilling and interfered with his longer-range plans: the hall- mark of executive dysfunction.
Tom and his CBT therapist identified the behaviors he would like to reinforce in a competing “exercise” script. It was helpful to introduce the coping skill of entering a room with a plan. This phrase is used to reinforce how it is easy to fall into behavioral patterns that are prone to disruption by various sources of interference or temptations unless there is a competing option. Thus, in Tom’s case, he focused on “entering his apartment with a plan,” a behavioral plan that he could execute instead of his overlearned habit of sitting on the couch and watching television. Changing the behavioral script involves defining “tip- ping points” at which different behaviors can be implemented.
Tom noted that he used to enjoy running and that it would be a good activity for him when he arrived home from work. He and his therapist defined the specific steps he would follow when he arrived home from work that would promote the likelihood he would go for a run, that is, “enter the room with a plan.” Tom said that the plan of going for a run sometimes seemed overwhelming—he could not reconcile feeling somewhat tired after work with the image of exerting himself. Tom and his therapist developed a step-by-step plan or “recipe” he could follow when he arrived home (e.g., “I will set down my things from work, I will go to my bedroom and put on my running clothes, I will get my iPod, and I will walk out the front door and start running.”). Tom identified
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the rationalizations that might interfere with his plan (e.g., “I’m too tired. I’ll relax first and run later.”) and developed adaptive responses (e.g., “I know I won’t run later. I always feel better and more energized after a run. Once I get started, it will be easier.”).
Tom’s plans for handling difficulties that could interfere with the implementation of his plan also were reviewed (e.g., “How will you handle it if your iPod is not charged?”).
The new behavioral script helped Tom to increase the number of times in a week he went running, providing him an opportunity to develop a reasonable routine. Using this template for changing entrenched behaviors, similar approaches were used to help Tom engage in other tasks he had been putting off, such as researching certification programs relevant to his job and taking care of simple errands, such as food shopping after work.
In addition to the positive reinforcement of behavior (i.e., the introduction of a posi- tive stimuli to increase the frequency of a behavior), it is important to help adults with ADHD recognize the role of negative reinforcement (i.e., the removal of an aversive stimuli to increase the frequency of a behavior) in maintaining behavior. Negative rein- forcement is particularly relevant for targeting escape behaviors that undergird procras- tination and avoidance.
For completeness, it should be pointed out that negative reinforcement is different from punishment. Punishment is the introduction of a consequence that reduces the frequency of a behavior. A positive punishment is characterized by the introduction of an aversive consequence, such as a speeding ticket or criticism from a boss for being late.
Negative punishment is characterized by the removal or loss of a desired stimulus or opportunity, such as losing an opportunity to take a class by missing the enrollment deadline or having to miss watching a football game on the weekend to catch up on overdue work.
Intact executive functions help individuals to organize and follow through on behav- iors that have long-range benefits but that might not be immediately reinforcing (e.g., working on a paper due next week), or at least not as compelling as other available options (e.g., watching a football game on television). Adults with robust executive functions are able to generate motivation associated with the future benefits of following through on priority tasks in the here-and-now, perhaps demonstrating “grit” (Duckworth, Petersen, Matthews, & Kelly, 2007), which is a penchant for goals that require sustained effort to achieve.
Adults with ADHD, on the other hand, experience motivational deficits that make it harder to generate this sort of motivation for long-range outcomes. They are also prone to succumb to immediately pleasurable activities, or the positive visceral feeling of relief that is experienced at the moment a choice is made to avoid working on the paper (i.e., escape from emotional discomfort) and instead to watch the football game, a textbook example of the negative reinforcement (i.e., removal of stress) of escape behavior. This pattern makes it more likely that the person will engage in avoidance/
escape in the future.
Most behavioral interventions focus on helping adults with ADHD to engage in tasks that are typically avoided, at least until facing a deadline. More specifically, these inter- ventions require a degree of tolerance of discomfort (i.e., frustration tolerance) in order to engage in a task. The primary objective is for the patient to experience positive rein- forcement for task engagement/completion instead of negative reinforcement from escape behavior (i.e., avoidance).
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In instances like procrastination, an adult with ADHD has the skills and capacity to complete a task, but struggles with negative anticipatory thoughts and feelings leading to a performance deficit. In cases where there are skill deficits, and where the goal is to learn and practice new coping behaviors, there may be issues related to low confidence related to trying new things, or worries about making mistakes that others might notice.
In either case, behavioral interventions provide progressive exposure experiences that enable adults with ADHD to follow through on personally relevant objectives so as to gain new experiences in managing uncomfortable emotions, to learn new coping skills, and to change their outlooks and attitudes.
Behavior change is difficult, particularly for adults with ADHD who must grapple with the fact that they have greater difficulties with the delay of gratification that makes them prone to give into distractions and other compelling temptations. What follows are additional interventions we have employed in the treatment of adult ADHD that func- tion synergistically and augment the cognitive and behavioral interventions described above.
Implementation Strategies
ADHD is a performance problem more than it is an information problem. Most adults with ADHD will report “I know what I need to do, but I cannot get myself to do it” or “I could coach someone else in how to handle a situation, but I cannot take my own advice.”
Therefore, it is essential to augment the aforementioned elements of CBT for adult ADHD with strategies designed to increase the performance of the various coping skills for managing ADHD and executive dysfunction.
We have found the research on specific implementation intention strategies (Gollwit- zer & Oettingen, 2011), as well as other interventions focused on motivational enhance- ment and follow-through on coping strategies to be useful extensions of CBT for adult ADHD. This research has focused on improving follow-through on health care recom- mendations and other aspects of treatments that require the active participation of, and performance by, patients to gain optimal outcomes. More specifically, implementation intention strategies have been modified for use with children with ADHD (Gawrilow &
Gollwitzer, 2008; Gawrilow, Gollwitzer, & Oettingen, 2011a, 2011b), and there are obvi- ous applications for adults. The motivational deficits associated with ADHD also require consideration of ways to enhance follow-through. (We will use the term “implementa- tion strategies” as an umbrella term for specific implementation intention strategies and other interventions that promote implementation.)
Implementation strategies can be considered a form of cognitive rehearsal for how to handle certain situations that occur in specific contexts: “Self-regulation by implementa- tion intentions entails delegating action control to pre-specified critical environmental cues” (Gawrilow & Gollwitzer, 2008, p. 263), thereby externalizing tactics to promote the use of executive function coping skills. That is, in addition to identifying opportunities for using coping skills and thinking through risk factors associated with a situation, specific behavioral tactics are outlined that define how coping plans will be employed as well as maintained in the face of potential distractions. Considering the role of emotions in moti- vation, coping plans will involve handling the affective associations with various plans in context. Implementation intention theory posits that these rehearsed, prespecified
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environmental cues operate by externalizing the executive functions, becoming activated if and when those situations are encountered. Thus, the implementation intention “If I take the incoming mail to my kitchen table, then I will sort through it and only keep bills and other items requiring action” should increase the likelihood of completing this task once a person retrieves that day’s mail. Similarly, the behavioral scripts previously discussed in the section on behavioral modification lend themselves to an implementation focus.
In addition to initial task engagement, we have found implementation strategies useful for helping patients persist on task, stop and transition to new tasks, and avoid perseveration (i.e., getting stuck), which is consistent with their self-regulatory func- tions (Gollwitzer & Oettingen, 2011). These strategies provide patients with mindsets and tactics with which to handle the typical distractions and frustrations they encoun- ter when using their coping strategies. Said differently, specific vulnerabilities stem- ming from ADHD are anticipated insofar as they may arise in a particular setting.
“If-then” coping plans are developed to address these vulnerabilities (Gawrilow &
Gollwitzer, 2008). Specified pivotal situations or “tipping points” that pose a risk for activating maladaptive patterns are identified, offering an opportunity to employ an adaptive executive function coping skill instead. The “risk” in the context is thus asso- ciated with an “if-then” coping scenario, so the “risk” now serves as a “cue” to promote an adaptive response. Individuals with intact executive functioning and motivation are generally able to navigate these processes in daily life, using executive skills like
“error detection,” “interference control,” “problem management,” and subsequent
“task persistence.” Adults with ADHD, on the other hand, benefit from explicitly dis- cussing these plans and rehearsing follow-through options to combat executive dys- function and motivational deficits.
For example, Tom, the young man who left work with plans for exercise, later focused on looking into certification programs for his job, but encountered other difficulties fol- lowing through. In particular, it was difficult for him to initiate research on the availabil- ity of such opportunities. He developed a “behavioral script” in which he arranged a realistic expectation for his objective (e.g., “I will look on the Internet and find out when and where the certification programs are offered, their cost, etc.”), a defined location (e.g.,
“I will go to the local coffee shop that has free Wi-Fi.”), and a realistic task and time frame (e.g., “If I go to the coffee shop at 10 a.m. on Saturday morning, then I will spend at least 30 minutes on my search before I take a break.”). Cognitive interventions were used to address task-interfering thoughts (e.g., “I usually do not like doing work on the weekend, but this is an important project for me and 30 minutes is not a long time. I’ll still have my whole Saturday ahead of me, and I will feel good about what I accomplished.”).
Implementation strategies further enable follow-through by anticipating and devel- oping strategies for handling examples of executive dysfunction that could undermine the performance of this plan. Tom and his therapist anticipated a number of possible scenarios that could disrupt his adaptive behavioral script, e.g., “What if the coffee shop is crowded and there are no seats available?” “What will you do if the Wi-Fi is down or you cannot connect to it?” or “What if you are there and a friend of yours happens to show up?” Plans for managing these scenarios are talked through, which follows the model of using if-then coping plans (e.g., “If it is too crowded, then there is a fast food restaurant across the street where I can go that offers Wi-Fi. If the Wi-Fi at these places is not working, my home Internet provider has hotspots that I can access using my
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account.”). All contingencies cannot be anticipated, but this rehearsal creates “cues” for adaptive coping with the common risks inherent in a particular situation.
In this vein, we have increasingly found it useful to differentiate between a goal focus and an implementation focus for behavioral objectives. Having these two mindsets with which to approach behavior modification plans also help overcome barriers to change.
A goal-focused orientation is a familiar and intuitive approach for achieving desired behavioral outcomes. There is a specific desired outcome or product that an individual hopes to achieve. This superordinate goal helps clarify and guide specific subordinate behavioral steps required to achieve it. For example, an individual might have the goal to keep up with paying bills and other household paperwork (e.g., renewing automobile insurance). This overarching goal helps her to review her incoming mail on a regular basis and to devote time to paying bills as they arrive. Such an outcome-driven goal is prudent and can be helpful for carrying out proactive behaviors.
However, such long-term outcome goals are often too distal and too weak for most adults with ADHD. Thus, these goals exert little influence on behavior at the point of performance. For example, an adult with ADHD has the goal to keep up with household bills and paperwork but feels overwhelmed when facing a stack of incoming mail (e.g., “I cannot deal with this right now. I’ll deal with it later.”). Driver’s license renewal or quar- terly tax payment paperwork appears confusing at first glance, does not require immedi- ate action, and is likewise set aside, either to be forgotten or only to be faced when the person faces an impending deadline or penalties for lateness. The “goal” of keeping up with paperwork remains intact but there are problems with daily follow-through.
In such cases, a reformulation of behavior change from an outcome focus to a proxi- mal, process focus may be useful. More specifically, adopting an implementation-focused orientation will better support improved self-regulation and behavioral follow-through (Gollwitzer & Oettingen, 2011). That is, we focus on defining specific, discrete imple- mentation tactics or steps that help the adult with ADHD engage in a task that increases the likelihood of follow-through on the overarching goal. Although poor task persis- tence and sensitivity to disruption affects most adults with ADHD, once they are engaged in a task, there is increased opportunity for the experience of positive feedback associ- ated with productivity along with a decreased sense of aversion to the task that facilitates ongoing performance.
For example, in the case of the individual with ADHD who has difficulty keeping up with bills and other household paperwork, there will be some component steps that interfere with following through on the goal, such as taking time to sort through the daily mail. Exclusive attention is paid to the relevant issues (e.g., automatic thoughts, avoidant behaviors) that may interfere with execution of that task and an alternative plan is developed (e.g., “What thoughts go through your mind when you see the pile of the day’s mail? What do you end up doing?”). Thus, rather than focusing on a large goal (e.g., keeping up with bill and paperwork) the patient focused on the steps required to initiate sorting through that day’s mail (e.g., “Let me first go through each piece of mail and discard the unnecessary items. I’ll then open the envelope that seems most impor- tant and deal with it”). Potential barriers to follow-through are identified and addressed, thereby these “risks” are turned into “cues” for good coping (e.g., “If I think I can do this task later, then I will remind myself that it will probably take less than a minute and then it will be done,” or “If my dog bothers me to go outside, then I will bring the mail with