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Library of Congress Cataloging-in-Publication Data

Names: Ramsay, J. Russell, author.

Title: Rethinking adult ADHD : helping clients turn intentions into actions / by J. Russell Ramsay.
Description: Washington, DC : American Psychological Association, [2020] | Includes bibliographical
references.
Identifiers: LCCN 2019023431 (print) | LCCN 2019023432 (ebook) | ISBN 9781433831560 (ebook) |
ISBN 9781433831508 (pbk.)
Subjects: LCSH: Attention-deficit-disordered adults.
Classification: LCC RJ506.H9 (ebook) | LCC RJ506.H9 R359 2020 (print) | DDC 618.92/8589—dc23
LC record available at https://lccn.loc.gov/2019023431
LC ebook record available at https://lccn.loc.gov/2019023432

http://dx.doi.org/10.1037/0000158-000

10 9 8 7 6 5 4 3 2 1
 This book is dedicated, as always, to my daughters,
Abigail and Brynn, and to the memories of their beloved
grandmother—my mother, Mary Ann Ramsay (1941–
2015)—and their aunt—my sister, Jennifer Ramsay
(1970–2019).
CONTENTS

Acknowledgments
Introduction

 1. Introduction to Adult ADHD

Contemporary Formulation of Adult ADHD
ADHD Within a Unified Theory of Psychology
Prevalence, Persistence, and Comorbidity and Impairments of Adult
ADHD
Conclusion
Key Clinical Points

 2. Clinical Outcome Research for Adult ADHD

Treatments for Adult ADHD
Research Relevant to the Cognitive Behavior Therapy Model of Adult
ADHD
Conclusion
Key Clinical Points

 3. Cognitive Behavior Therapy Model of Adult ADHD

Cognitive Behavior Therapy Case Conceptualization
The Generic Cognitive Model and Its Relevance for Adult ADHD
 Primary Cognitive Theme of Adult ADHD
Cognitive Behavior Therapy Model for Adult ADHD
Conclusion
Key Clinical Points

 4. Cognitive Interventions Adapted to Adult ADHD

Identifying Thoughts and Their Effects
Cognitive Modification: Retaining Your Defense Attorney
Cognitive Defusion
Cognitive Framing and Reframing
Cognitive Modification for Common Distortions
Other Cognitive Change Tactics
Conclusion
Key Clinical Points

 5. Cognitive Interventions in Action: Common Issues in

Cognitive Behavior Therapy for Adult ADHD
Engaging in Treatment
Procrastivity and Adult ADHD
Managing Procrastination: How You Donʼt Do Things
Time Management Challenges
Attitudes About Organization
Emotional Management Difficulties
Tolerating Discomfort: Taming the Ugh
Reining in Impulsivity
Manufacturing Motivation and the Valuation of Tasks
Assertiveness as an ADHD Coping Strategy: Define Your Role
Using Coping Strategies and Handling Setbacks
Changing Maladaptive Schemas/Core Beliefs
 Conclusion
Key Clinical Points

 6. Additional Clinical Issues in Cognitive Behavior Therapy

for Adult ADHD
Medications
Emerging Adults With ADHD
Comorbid Anxiety, Depression, and Substance Use
Sleep Problems
Technology
Relationships
Senior Adults With ADHD
Suicidality
Managing Oppositional Behavior
Therapist Reactions/Misconceptions
Conclusion
Key Clinical Points

 7. Case Examples
Grace-Ann
Evan
Kurt
Conclusion
Final Thoughts

Appendix. Credible Sources of Information About Adult ADHD

References
About the Author
ACKNOWLEDGMENTS

First and foremost, I want to acknowledge the adults with attention-

deficit/hyperactivity disorder (ADHD) whom the University of Pennsylvaniaʼs
Adult ADHD Treatment and Research Program has been privileged to serve. I
have heard scores of personal accounts of life with ADHD and the related
struggles, as well as stories of muddling through, managing, and eventually
transcending these struggles, in whatever fashion, and these accounts and the
irrepressibly hopeful, gritty attitudes that promote these efforts have been a
central inspiration for this book. My hope is to give other clinicians a glimpse
into these frames of mind as best as I can from having sat across from countless
adults with ADHD, listened to them, and hopefully and most importantly “got
it,” thereby being able to offer some measure of help as they aimed to better their
lives.
I owe a deep debt of gratitude to the many clinicians, trainees, and staff who
have been a part of this program since its inception in 1999. The program has
grown from a two-person operation to a full roster of psychiatry residents and
advanced doctoral students in clinical psychology who complete year-long,
supervised trainings in the assessment and treatment of adult ADHD. We have
also benefitted from many individuals who have helped out in various roles (e.g.,
intake coordinators, testers, research assistants) and many colleagues involved in
the business and operations of our department, including our past and present
department chairs, Dr. Dwight Evans and Dr. Maria Oquendo, respectively.
Of course, the Penn Adult ADHD program would not have been the focal
point of my career but for Dr. Anthony Rostain, who is psychiatrist, colleague,
and friend extraordinaire. I am one of those individuals whose specialty found
him in the form of being invited by Dr. Rostain to join with him to set up a
clinical program targeting the needs of adults with ADHD. Over countless face-
to-face meetings, we shared ideas about the direction of our program; would-be
projects; timely issues in our field; and various ways to develop, hone, advance,
and distill assessment and treatment strategies that hold the promise of offering
real-world benefits in the lives of adults with ADHD. Our conversations are as
lively and invigorating, if not more so, than when we started.
Over the past several years, Lisa Joy Tuttle, who has developed a Mindful
Self-Management group program for executive functioning skills, has become an
integral part of our ADHD program. She has been a valued collaborator with
unique perspectives who, along with Dr. Rostain and me, constitutes the three-
legged stool of leadership at the Penn Adult ADHD program.
I would also like to thank two of my mentors, Dr. Leonard I. Jacobson and
Dr. Anita L. Greene, my undergraduate and graduate advisors, respectively. I
sought out each of them because they had reputations for being challenging,
even intimidating, insofar as they were known to have high standards for their
students. These reputations were accurate but incomplete; each was a committed
teacher, mentor, and source of support. Neither of them would allow me to avoid
a challenge that I was ready to tackle; but neither one would force me into a role
I was not ready to assume. I rounded out my formalized training with a
predoctoral internship at CPC Behavioral Healthcare in Red Bank, New Jersey,
and a postdoctoral fellowship at the Center for Cognitive Therapy at the
University of Pennsylvania, where I am still a senior staff clinician.
A special word of thanks goes out to everyone at Broad Street Grind, a coffee
shop in Souderton, Pennsylvania, that was my workstation for this book. Almost
every Saturday morning I was at the door when it opened. The owner, Phil
Shade, the baristas, and everyone else there were always friendly and
accommodating, and kept up with my progress on the book. (Of note, my
previous two books were written at Main Street Java, not far from where Broad
Street Grind is located, which sadly closed for good just weeks before their
release. I do not believe in jinxes or superstitions, but I hope Broad Street Grind
does not suffer the same fate.)
I wish to thank American Psychological Association Books, Acquisitions
Editor Susan Reynolds, and Development Editor Kristen Knight. From the first
mention of this book (among a few other ideas), Susan advocated for it as a
worthwhile project. As with a previous book I published with the American
Psychological Association for which Susan was editor, she allowed me to
produce a work with which I was pleased and then handed me off to Kristen and
her team, who guided me through the editing and publication process to end up
with a book to which I am proud to affix my name. The final product was made
so very much better by the thorough and astute suggestions made by Drs. Brad
Rosenfield, John Mitchell, and Laura Knouse, each an expert on this topic in
their own right. I am grateful for the time and effort they took from their busy
schedules to do so; each one is a valued colleague.
My parents, the late Mary Ann Ramsay and the late J. Roger Ramsay, were
unending sources of support, and I will forever count myself lucky to have been
their son. They each conveyed a modest, unassuming, but purposeful approach
to life in which one works hard, tries to do the right thing, and quietly tries to
make the world a better place in the process. My sister, Jennifer Ramsay, who
sadly died during the final edits of this book, was a source of inspiration by the
spirit with which she approached her all-too-brief life.
My biggest debt of gratitude goes to my wife, Amy, and my daughters,
Abigail and Brynn. Abby and Brynn are strong-willed young women with an
independent streak, each in her own way, that is driving them down unique paths
in life. I am immensely proud of them. Amy and I have been together for more
years than not by this point in our lives. Whether we are doing something or
doing nothing much at all, I still enjoy hanging out with my wife.
Introduction

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.

THE COGNITIVE THEME IN ADULT 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.

INTENDED READERSHIP

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.
OVERVIEW OF THE BOOK

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.

CONCLUSION

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.

1All clinical case material has been altered to protect client confidentiality.
2For a clinical demonstration of many of the ideas described in this book, see Adults With ADHD, an
American Psychological Association video now available at
https://www.apa.org/pubs/videos/4310004.html.
1
Introduction to Adult ADHD

Before the role of thoughts and beliefs in the experience and treatment of
adults with attention-deficit/hyperactivity disorder (ADHD) is addressed, it is
important to establish a shared foundation of the contemporary view of ADHD.
This step is necessary to grasp what adults with ADHD have faced in their lives
and what is being targeted in treatment. Unlike mood and anxiety disorders,
which are staples of clinical training for mental health professionals, most
clinicians and clinicians-in-training have had scant, if any, exposure to adult
ADHD (Willer, 2017).
The goal of this chapter is to provide a clinician-friendly overview of the
current state of the field in terms of understanding ADHD, its etiologies, and
how this translates into clinical presentations and difficulties faced by adults
seeking help. The first section of this chapter reviews the modern-day view of
ADHD as a neurodevelopmental disorder of impaired self-regulation. This
definition moves beyond the symptom criteria listed in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American
Psychiatric Association, 2013) and other classification systems and instead
focuses on sound models that are more clinically useful in terms of recognizing
the central features of ADHD. These models help therapists better detect or
“see” ADHD and its effects on functioning rather than merely try to determine
whether a clientʼs attention, hyperactivity, and/or impulsivity reflect levels that
are too much, too little, or just right. Within this framework, therapists are better
equipped to understand and treat adult ADHD more effectively. Interacting
neurobiological systems that underly these self-regulation difficulties are
introduced to provide a sense of what drives the symptoms and downstream
functional impairments. The relevance of these aspects of self-regulation will
also be examined through the lens of a broader, similarly evolution-based theory
of psychology to further illustrate the effects of self-regulation deficits
characteristic of ADHD on some important behavioral, social, and cognitive
psychological mechanisms0.
After reviewing the nature of the disorder, the discussion moves to the real-
world effects of ADHD on “free range humans”—individuals who seek
treatment for the life difficulties presented in these last sections. Information is
presented about the prevalence and persistence of ADHD into adulthood and
factors most germane to this population. In particular, the common life problems
faced by adults with ADHD are reviewed, as these are the sources of distress
that lead most people to seek help. Indeed, it is these struggles that shape and are
shaped by the thoughts and beliefs observed when helping adults with ADHD.

CONTEMPORARY FORMULATION OF ADULT ADHD

ADHD has gone through several name changes over the years, and the
assumptions about the essence and etiologies of this disorder also have changed
(see Barkley, 2015a, for a review of this history). Although the official
symptoms comprising a diagnosis have been relatively stable, there is now a
broader understanding of the clinical features, the underlying mechanisms
driving these features, and their relevance for the functioning and well-being of
adults with ADHD. This discussion begins with the current diagnostic criteria
for ADHD.

Symptom Definition
The DSM–5 (American Psychiatric Association, 2013) places ADHD in the
Neurodevelopmental Disorders section. The diagnosis is defined by a list of 18
symptoms evenly divided between the hyperactive/impulsive and inattentive
domains, with symptom defined as developmentally inappropriate levels of any
features that individually and cumulatively create impairments. The two
symptom domains yield three possible presentations of ADHD: predominantly
hyperactive/impulsive presentation, predominantly inattentive presentation, and
combined presentation.
There have been some changes in the DSM–5 relevant to the diagnosis in
adults. The symptom threshold for diagnosing ADHD in adults has been
lowered. Previous criteria required the presence of six of nine symptoms in
either of the symptom domains as the diagnostic threshold for clients of all ages,
which remains the threshold for children and adolescents. The cutoff for adults
has been lowered to five of nine symptoms because some symptoms are less
applicable to adults, and a lowered threshold is a better marker of developmental
deviance in adults (Barkley, Fischer, Smallish, & Fletcher, 2002).
In addition, a long-awaited change to the age-of-onset criterion was made,
now requires several symptoms be present before 12 years old rather than 7
years old. Full diagnostic criteria in childhood is not required for a diagnosis in
adulthood, rather it is the emergence and persistence of symptoms that have been
observed in childhood. Several studies indicate that an age of onset by late
adolescence is adequate (Barkley, Murphy, & Fischer, 2008; Polanczyk et al.,
2010), as there is no clinical difference between adults diagnosed with ADHD
and those who fulfill all other diagnostic criteria except for age-of-onset
(Faraone et al., 2006).
There is no separate symptom list for adult ADHD as the existing symptom
criteria is unchanged since the fourth edition of the DSM (DSM–IV; American
Psychiatric Association, 1994). The recently updated 11th edition of the
International Classification of Diseases (ICD–11; World Health Organization,
2018) uses the term ADHD as well as the same three presentation types and age-
of-onset criteria as the DSM–5.
Several recent studies have cited the phenomenon of adult-onset ADHD
(Agnew-Blais et al., 2016; Caye et al., 2016; Moffitt et al., 2015), which are
cases in which diagnostic levels of symptoms and impairments arrive de novo in
adulthood with no previous evidence of any signs of ADHD. Typical adult
ADHD represents either individuals diagnosed in childhood who continue to
manifest symptoms in adulthood or individuals not identified with ADHD until
adulthood but for whom retrospective review establishes the earlier emergence
of symptoms, which is considered standard practice in the evaluation of ADHD
(Ramsay, 2017a).
The notion of adult-onset ADHD stems from studies using retrospective
assessment of childhood symptoms along with assessment of current symptoms
and documenting the presence of ADHD in adults who did not show symptoms
in childhood. In a couple of studies (Agnew-Blais et al., 2016; Caye et al., 2016),
the adult samples comprised 18- and 19-year-olds, which represents a blurry
developmental line between adolescence and adulthood (Faraone & Biederman,
2016). However, another study (Moffitt et al., 2015) comprised developmentally
mature adults and provided preliminary data that call into question the age-of-
onset criterion.
On the other hand, a study with rigorous, repeated evaluations of children
(those with ADHD and those without ADHD) tracked into young adulthood
indicated that adult-onset cases were the result of ADHD-like symptoms
associated with other clinical factors (e.g., the effects of substance use, a
comorbid disorder, cognitive fluctuations that were not deemed impairing) and
not ADHD itself (Sibley et al., 2018). A more recent study failed to find
evidence supporting adult-onset ADHD in a longitudinal sample of women with
similar alternative explanations for emerging attention deficits (Ahmad, Owens,
& Hinshaw, 2019). The practice standard continues to be a thorough review of
the timing of symptom onset and persistence in all adult cases, including
retrospective accounts of prominent subthreshold symptoms of ADHD or
difficulties in childhood for which treatment was not sought until adulthood
because of attenuating factors (e.g., intelligence, dismissive attitudes toward
diagnosis; Kooij et al., 2019; Mitchell et al., 2019; Ramsay, 2017a). These cases
are better referred to as late identified rather than adult onset.
With the advent of these modifications, there is now a corresponding adult
ADHD module included in the Structured Clinical Interview for DSM–5 (First,
Williams, Karg, & Spitzer, 2016). There are several other structured interviews,
symptom checklists, and norm-based adult ADHD inventories that include DSM
symptoms but cast a wider net to cover a range of symptom and functional issues
experienced by adults with ADHD. Use of structured interviews, inventories,
and assessment for and ruling out other psychiatric and medical conditions that
could mimic symptoms of ADHD remains the diagnostic standard. The notion of
neuropsychological testing as a central means for assessing ADHD and
impairments is appealing but poses a risk for false negative cases insofar as
time-limited, office-based tests do not capture the temporal challenges of
organizing and managing the affairs of daily life. (See Barkley, 2019; Mapou,
2019; Ramsay, 2015, 2017a, for reviews of issues related to the assessment of
adult ADHD.)
The diagnostic category and acronym of ADHD is well-established and will
likely not soon change. However, futile arguments over the attention and
hyperactivity aspects get in the way of distinguishing the essential nature of the
condition. Characterizing ADHD based solely on the current list of symptoms is
akin to branding panic disorder as a “tachycardia disorder” (Ramsay & Rostain,
2015b) or autism as an “eye-gaze disorder” (R. A. Barkley, personal
communication, June 5, 2019) as these views reflect discrete features of each
disorder but do not embody their essence. The next section moves beyond DSM
symptoms to review the prevailing view of the essence of the ADHD syndrome.

ADHD as a Neurodevelopmental Disorder of Impaired Self-Regulation

A parsimonious description of the contemporary view of ADHD is that it is a
neurodevelopmental disorder of impaired self-regulation—a chronic, persistent
delay in the acquisition of various normative and interacting self-control and
self-management faculties in age-appropriate roles and settings and a
corresponding deficit in the operation of these faculties. ADHD reflects a
quantitative rather than a qualitative difference in course and presentation
compared with other conditions (R. A. Barkley, personal communication,
September 30, 2017).
ADHD is a dimensional disorder in that its symptoms, features, and
impairments fall at the disordered end of a normative continuum of self-
regulation and functioning (Asherson & Trzaskowski, 2015; Katzman, Bilkey,
Chokka, Fallu, & Klassen, 2017). By definition (American Psychiatric
Association, 2013), adults diagnosed with ADHD experience more symptoms
with a greater degree of severity and magnitude of interference than adults who
encounter typical, fleeting, circumscribed fluctuations in self-regulation. A
thought disorder or a manic episode, by comparison, represent a qualitatively
different thought process or mood state, respectively, each signifying
dysfunction in an otherwise adaptive neurologic system and process.
A framework that has emerged over the past few decades for understanding
the different facets of self-regulation in adult ADHD has been centered on the
executive function (EF) construct. Definitions of EFs cluster around the ability
to persist on goal-directed plans by which clients choreograph higher-order
cognitive skills of planning, problem-solving, and information management and
orchestrating thoughts, emotions, and behaviors to achieve these ends (Barkley,
2001, 2012; Goldstein & Naglieri, 2014). These capacities are considered as top-
down regulatory skills needed to manage or override automatic, competing
inclinations in order to persist on deferred, valued goals and benefits. There is a
bidirectional link of these sort of top-down, self-directed actions and bottom-up
processes, such as alertness/detection (which allows humans to orient to key
signals in the environment) and information filtering/accumulation (which
allows for the processing and sorting of these signals and data); this information
is used to determine which actions are appropriate (Nigg, 2018a). The operations
of these processes are further influenced by personal experience (Barkley, 2016;
Blair, 2016).
An elegantly simple description of EFs and other operations of the frontal
cortex (where EFs reside) is that they are what “makes you do the harder thing
when itʼs the right thing to do” (Sapolsky, 2017, p. 45). This depiction captures
how a history of ADHD and related frustrations create negative outlooks and,
conversely, how cognitions can be marshalled to foster implementation of
strategies designed to promote adaptive change for adults with ADHD. The next
section reviews EFs and their relevance to ADHD with attention paid to their
effects on the cognitions of adults with ADHD. This discussion is followed by a
therapist-friendly review of prominent underlying etiologic factors for EFs and
other features of ADHD.

Executive Functions
EFs have been particularly relevant to the evolving conceptualization of ADHD
(Barkley, 1997, 2012, 2016; Brown, 2013, 2017; Kooij et al., 2019); in fact,
ADHD is often viewed as an executive dysfunction disorder. EFs are defined as
self-regulation in the form of self-directed behaviors used to specify and
organize goal-directed plans; to implement and sustain actions over time toward
these goals; to achieve the personally salient outcomes that will benefit
individuals by requiring interaction with others and social or cultural institutions;
and for which there is deferred outcome or reward and, very often, short-term
costs (Barkley, 2012). This definition encompasses the presenting complaints of
most individuals with ADHD.
EFs emerged as the most reliable diagnostic factor in adult ADHD, followed
by inattention/hyperactivity and impulsivity when using DSM–IV criteria
(Kessler et al., 2010). A study using DSM–5 criteria again found that EFs (now
coupled with inattention) emerged as the most discriminating factor ahead of
hyperactivity, impulsivity, and emotional dyscontrol (Adler et al., 2017). EFs are
highly correlated with DSM–5 symptoms (Silverstein et al., 2018), although they
do not appear in the diagnostic criteria. More to the point of clinical practice, the
EF model provides a useful lens through which to detect and target ADHD and
its effects.
Everyone has EFs—it is a distinctively human feature (other social animals,
particularly the more social ones, such as dolphins, chimpanzees, and some
species of monkeys also show rudimentary EFs; Barkley, 2012). People who
experience a depressive episode, deal with the effects of a concussion, or are
sick with influenza will experience diminished executive functioning. The issue
at hand for adults with ADHD is that they face a persistent, unremitting lag in
the development, maturity, and application of these skills compared with same-
age peers.
There is a developmental progression of the unfolding of EFs that is beyond
the purview of this book (see Antshel, Hier, & Barkley, 2014; Barkley, 1997,
2012, 2016, for extended discussions). However, aspects of these distinct EF
domains are reviewed next (in the order of their developmental unfolding;
Barkley, 1997) to highlight their relevance for cognitive behavior therapy (CBT)
for adult ADHD, particularly the cognitive domain.

Behavioral Inhibition
The ability to stop responding to the environment is the first EF to emerge (after
an awareness of self; Antshel et al., 2014; Barkley, 2016). This pause in the flow
of experience and action creates a space in which individuals can act proactively
with intention, rather than reactively to prepotent stimuli, which represent
compelling, habitual urges. This pause allows for a prolongation of a moment,
which provides an opportunity for the companion operations of reflection, the
mental review of the sequence of events, and proflection, or envisioning
different action scenarios or simulations to achieve a desired future outcome.
For children with ADHD, behavioral disinhibition manifests in difficulties
managing observable behaviors. Although motoric inhibition generally improves
with age (and brain maturation), adults with ADHD still often struggle with
other forms of disinhibition, such as impulsive spending, excessive or
inappropriate verbal behavior (e.g., saying the wrong thing at the wrong time),
and an internal sense of restlessness (e.g., a constantly bouncing foot). The
adaptive nature of self-inhibition for coordinating intentions and actions was
captured by Friedman (2016): “When you press the pause button on a machine,
it stops. But when you press the pause button on human beings they start” (p. 4).
From a standpoint of CBT, behavioral inhibition is needed to organize said
intentions and actions, including interrupting a behavioral sequence to switch to
another one. As mentioned previously, this mental and behavioral space provides
an opportunity to act with a directed purpose. The inhibitory step of the
prolongation of this time and mental space is a necessary one to identify and
assess thoughts and behaviors and their relationship to future-focused intentions.
CBT sessions serve an inhibitory function, which creates a space in time for
clients to reflect and proflect to coordinate their thoughts, feelings, and
behaviors with desired outcomes, rather than succumbing to impulsivity. This
process is an aspect of strategic metacognition, developing and externalizing
skills and plans to increase the likelihood they will be implemented at the point
of performance.

Nonverbal Working Memory

Nonverbal working memory (NVWM) is the capacity to hold events in mind in
the form of visual images, like a video replay of events. NVWM is essential for
the organization of behavior and synchronizing it with time (Barkley, 1997,
2016). This capacity allows individuals to hold and process different possible
scenarios in their minds and fix a desired course of action rather than relying
solely on trial-and-error learning. NVWM supports cognitive-imaginal rehearsal
of potential future actions, which is helpful for anticipating, practicing, and
ultimately handling potential difficulties, such as mentally preparing for a job
interview, or keeping in mind a goal to guide action toward it.
Visual images fall within the realm of cognitions in CBT. For example, when
a client describes putting off a monthly report for work, her thought about it may
appear as an image of herself “sitting there for an hour, stuck, frustrated, and
unable to get anything done.” This image contains a wealth of information that
provides targets for intervention, including reenvisioning her ability to handle
the task backed up with a personalized action plan for doing it.

Verbal Working Memory

Verbal working memory (VWM) reflects internalized speech or self-talk that
guides behavior, including automatic thoughts. The VWM model, as outlined in
Barkleyʼs (1997, 2016) hybrid model of the EFs for ADHD draws on a Skinnerʼs
(1957) behavioral model of the internalization of speech. What starts out as
babble and baby talk in infancy progresses through phases of overt commentary
on what a child sees or does to semicovert, self-guided instruction such as
talking through the steps of learning to tie shoes (“The bunny goes through the
hole and then pull the ears tight”). This commentary ultimately matures into
fully internalized and privatized self-talk in adolescence such as an adolescent
mentally cursing out his or her parents while remaining stone-faced as he or she
is grounded. Cognition in this view is treated as a verbal behavior derived from
individualsʼ conditioning history, the same as any overt behavior, and is
modified in the same manner as any other behavior.
This Skinnerian (1957) model of self-directed speech is useful for
understanding the internalization of speech across development and its role in
rule-governed behavior and cognition (see Hayes, Blackledge, & Barnes-
Holmes, 2002, for a modern behavioral view of language and cognition).
Critiques of this model (Chomsky, 1959) and cognitivist frameworks (A. T.
Beck, 1976; Mahoney, 1974; Meichenbaum, 1977) pose internal meaning-
making and justification processes as emergent features from this base.
Cognitivist models move beyond a strict conditioning model and impart an
inventive, creative, and constructive influence of cognitions as valued goals that
guide behaviors.
Suffice it to say, VWM extends to rule-governed behaviors and cognitions,
and is a facet of self-regulation. These cognitions affect how adults with ADHD
view their endeavors and themselves and thereby inform cognitive interventions.

Emotion Regulation
Emotions have never been mentioned in the criteria for ADHD in any edition of
the DSM, ICD, or other classification system. However, clinical observations
that inform ongoing research have established emotional dyscontrol as a core
feature (Adler et al., 2017; Barkley, 2015b; Kooij et al., 2019).
The emotional features characteristic of adult ADHD are not those of
disordered mood or anxiety, which may coexist with ADHD. Rather, emotional
dyscontrol seen in clinic-referred adults with ADHD represents maladaptive
reactions to the same emotionally charged triggers that affect everyone (Barkley,
2015b). The triggering events (external or internal), however, are more
distracting and disruptive for adults with ADHD and it takes them longer to tone
down these feelings (positive or negative). This dyscontrol reflects deficient top-
down regulatory skills for managing and modifying bottom-up emotional
reactions that are typically encountered in the course of managing adult life. This
usually manifests in adults with ADHD as repeated instances of overreacting to
relatively minor stressors, with the consequences of these reactions often
magnifying or adding to the original stressor.
Emotion regulation is also tied to motivation, which is relevant to ADHD. An
EF definition of motivation is the ability to generate an emotion about a task in
the absence of an immediate consequence (Barkley, 1997). This is the knack of
being able to change an emotional state by shifting attention, conjuring up
images, thoughts, and other behavior-facilitating drives to perform an action.
This is the emotional skill used by students to make them “feel enough” like
studying 3 days before an exam rather than waiting until the night before when
the motivating emotion is panic.
Emotion regulation is important for CBT, as the ability to modify emotions is
an overarching therapeutic component. A more specific issue in CBT for adult
ADHD is manufacturing motivation for various tasks (Ramsay & Rostain,
2015a). Task demands often trigger visceral feelings of discomfort, even subtle
ones. These are often described as gut feelings distinct from sadness or worry,
but rather the sense of “I know I have to do this but I do not want to do this,”
which can be potent enough to provoke escape-avoidance. An essential facet of
motivation and overcoming procrastination is to deal with an individualʼs
thoughts about tasks, including the relationship with emotions and discomfort.
Indeed, procrastination and other forms of disengagement are often fueled by
feelings of demoralization that originate from past failures and setbacks.

Reconstitution
The last EF to emerge is reconstitution, which derives from the childhood
capacity to play and explore. What starts as play in the form of discovering how
things work (e.g., taking things apart and putting them back together) or role-
playing cultivates a capacity to analyze, deconstruct, and synthesize information
and adopt different perspectives. This skill provides a platform for innovation
and problem-solving such as drawing from past experiences that approximate
newly encountered challenges (Barkley, 1997, 2016).
Reconstitution is relevant for cognitive interventions in CBT as it involves
recognizing and analyzing clientsʼ responses to events and synthesizing
alternative interpretations, reframes, and plans. Combined with NVWM and
VWM, these skills are used to anticipate situations and engage in prospective
problem-solving. This is particularly relevant for breaking down tasks into
discrete steps and fostering the execution of these steps over time. Again, the
ultimate outcome is behavioral (i.e., goal-directed behaviors), but cognitions
play an important mediational role in the process. Task-promoting thoughts (and
mitigating task-demoting thoughts) foster the application of coping strategies
and behavioral follow-through that furnish adults with ADHD with novel
experiences, improved well-being, and new outlooks.

Summary
Each successive EF draws on the foundation established by the previous one.
Relative deficits and delays in EF skills have effects on subsequent skill
acquisition and execution. In addition to their direct role in functional problems,
EF deficits have secondary effects on the ongoing acquisition and use of coping
skills, including compensatory skills for ADHD (see Barkley, 2012).
ADHD is increasingly viewed as an EF-deficit disorder, but with an
assortment of processes underlying these executive skills (Castellanos & Proal,
2012; Kooij et al., 2019; Sonuga-Barke, 2010). Although tethered by common
and overlapping symptoms and self-regulation difficulties, there are other factors
at work in self-regulation and the observable features of ADHD, which are
summarized next.

Etiologic Models of Self-Regulation and ADHD

Genetic research consistently shows that heredity, on average, accounts for
about 80% of individual differences in ADHD symptoms, including studies of
identical twins reared together versus those reared apart and adopted childrenʼs
environment versus the traits of birth parents (Barkley, 2015a; Brainstorm
Consortium, 2018; Demontis et al., 2019; Faraone & Larsson, 2019). ADHD and
its features cluster within families, both immediate and extended. ADHD is one
of the most highly heritable conditions seen in clinical psychiatry and
psychology, though this fact only establishes a propensity or relative risk for
manifesting symptoms or the full disorder. Genetic unfolding most definitely
interacts with environmental or epigenetic factors (see Neuman et al., 2007;
Nigg, 2018a, 2018b) and a recent genome-wide meta-analysis (Demontis et al.,
2019) has yielded a specific set of genetic risk factors for ADHD.
Similarly, neuroimaging research offers compelling details about
neurobiological underpinnings of ADHD (see Barkley, 2015a; Bush, 2010;
Cortese & Coghill, 2018; Konrad & Eickhoff, 2010; Kooij et al., 2019; Purper-
Ouakil, Ramoz, Lepagnol-Bestel, Gorwood, & Simonneau, 2011 for reviews).
Inefficiencies in the prefrontal cortex and anterior cingulate are familiar leading
players, but structural studies have also implicated alterations in the basal
ganglia and subcortical reward networks. From a functional standpoint,
hypoactivity in the frontoparietal and ventral attention networks has been
documented in studies of ADHD, as has hyperactivity in the default mode
network and the visual network. Studies have shed light on differences in the
growth, size, and volume of different brain regions (Proal et al., 2011; Shaw et
al., 2007, 2012, 2018), comparing individuals with ADHD with individuals
without ADHD and, among individuals with ADHD, comparing those with
better function with those with worse functioning (Mackie et al., 2007). This line
of research helps explain the heterogeneity of ADHD cases as some individuals
experience symptom reduction or remission by adulthood, whereas others have
persistent symptoms (e.g., Barkley et al., 2008).
Dopamine deficiency models are based on studies of dopamine availability in
the subcortical reward networks of the brain, with less availability (fewer
dopamine receptors and transporters) seen in imaging studies of adults with
ADHD compared with adults without ADHD (Volkow et al., 2009, 2011).
Dopamine availability correlates with self-reported ADHD symptoms and self-
ratings of trait motivation, with low dopamine associated with higher ADHD
symptom ratings and lower trait motivation ratings. This finding is relevant to
clinical issues of procrastination and poor task initiation, as well as proneness for
addictive behaviors, including excessive gaming and technology use. In fact, the
dopamine reward system is as much, if not more about the anticipation of a
reward as its pursuit and attainment (Sapolsky, 2017), which is directly relevant
to adult ADHD and cognitions about task plans and coping strategies versus
succumbing to distractions and avoidance.
The dopamine deficiency model is consistent with wider ranging reward-
deficiency models of ADHD (Sonuga-Barke, 2010, 2011; Willcutt, 2015), which
may be more precisely viewed as differences in responsiveness to typical
rewards and their presentations among adults with ADHD, such as stimulus
seeking and greater sensitivity (irritability) to reduction in rewards. Tied to
reduced reward signals in the ventral striatum, such reward deficiency manifests
as problems orienting to sources of rewards and being less responsive to rewards
that are sufficiently reinforcing for nonclinical groups; these factors present as
delay aversion, proneness to boredom, and temporal discounting (i.e.,
impulsivity in chasing more immediate rewards over more valued but deferred
rewards). These factors all undermine typically advisable behavioral
interventions if not modified for ADHD. Individuals with ADHD require more
timely, frequent, salient, and stronger rewards to shape behavior.
The default mode network (DMN) is in the precuneus, a structure buried deep
in the brain that is the seat of resting-brain activity (Utevsky, Smith, & Huettel,
2014). The DMN plays a crucial role in the attention difficulties seen in adult
ADHD. The DMN refers to the resting mental state and task-irrelevant mental
processes of the brain in an idling mode, such as mind-wandering (Franklin et
al., 2017). Problems in ADHD occur when the brain must shift out of this resting
state. This shifting process requires that the default network be suppressed while
the brain engages in concentrated attention. The requisite degree of suppression
(default mode deactivation) is positively associated with the difficulty of a task
at hand (McKiernan, Kaufman, Kucera-Thompson, & Binder, 2003). Default-
mode interference when shifting modes is likely a key source of attention
problems and inconsistent reaction times for adults with ADHD (Castellanos et
al., 2008; Sonuga-Barke & Castellanos, 2007). Connectivity patterns between
the DMN, saliency network (bilateral insula and anterior cingulate cortex), and
the twofold dorsal and ventral attention networks (the where and to what an
individual attends, respectively) may play a central role in the proneness for
distractibility and mind-wandering problems seen in ADHD (Bozhilova,
Michelini, Kuntsi, & Asherson, 2018; Sidlauskaite, Sonuga-Barke, Roeyers, &
Wiersema, 2016; Silberstein, Pipingas, Farrow, Levy, & Stough, 2016).
ADHD has many strong genetic and neurobiological underpinnings
(interacting with epigenetic factors) that are associated with the operations of a
variety of interrelated brain networks. These networks have downstream effects
on functioning in daily life; aspects of life that those without ADHD may take
for granted become much more difficult for individuals with ADHD. In real
time, these neurobiological inefficiencies conspire to interfere with initiating and
shifting between tasks that is made even more difficult by an impaired ability to
motivate and sustain effort toward a deferred goal, particularly in the face of
dissuading factors competing for time, attention, and effort.
Before examining the prevalence of adult ADHD and specific domains of
impairment in the modern world, the self-regulation/EF view of ADHD is
reviewed within a broader theory of psychology to examine the effects of ADHD
on some relevant psychological mechanisms. Advances in understanding ADHD
have come from adopting a wider scope that includes neurobiological and
evolutionary models (Barkley, 2001, 2012). The next section will use the unified
theory of psychology (Henriques, 2011) as a theoretical context for
understanding the relevance of ADHD to some broader psychological
mechanisms, which will also have implications for later discussions of the CBT
model of and treatment for adult ADHD.

ADHD WITHIN A UNIFIED THEORY OF PSYCHOLOGY

Coming from a background in the study and practice of professional clinical

psychology, Henriques (2011) took on the ambitious task of proposing a unified
theory of psychology comprising four broad facets: First, human psychology
derives from an evolutionary context. This facet is consistent with advances in
understanding EFs as an example of an extended phenotype or how certain
behaviors are genetically maintained in a species by their advantageous effects
on an organismʼs environment (Barkley, 2001, 2012; Dawkins, 1982/1999). The
remaining three facets of the unified theory of psychology include the behavioral
investment theory, the influence matrix, and the justification hypothesis. These
facets are relevant for further understanding and appreciating the effects of
ADHD and EF deficits on functioning, namely, their effects on behavior,
relationships, and cognitions, which correspond with different domains of CBT
for adult ADHD.

Behavioral Investment Theory

Within behavioral investment theory, the nervous system treats behavior as
commerce or an investment (Henriques, 2011). There is a largely nonconscious
cost–benefit calculation of the time, effort, and energy costs associated with any
particular action. This calculation is associated with innate propensities toward
certain stimuli as well as those tied to individual issues of heredity and
experience, like behavioral selection (Skinner, 1981).
The primary relevance of behavioral investment theory is the effect of ADHD
on these cost–benefit calculations of intentions/actions, which operate as a sort
of behavioral loan officer. The EF deficits associated with ADHD make many
pursuits and endeavors in life more difficult to manage for adults with ADHD.
There are many endeavors, including those highly valued and otherwise deemed
as “good” investments from a logical standpoint, for which the nonconscious
cost–benefit of the investment of time, effort, and energy expenses by adults
with ADHD yield reflexive conclusions that they are “bad” investments. This
ambivalence, the battle between logically knowing what needs to be done and a
nonconscious calculation of it as untenable because of EF deficits, represents a
difficulty voiced by most adults with ADHD, the maddening, seemingly self-
defeating escape–avoidance, procrastination, and disengagement seen in ADHD
despite valued intentions. The repeated fatigue and demoralizations from this
tug-of-war between the rationally defined good investments and the visceral,
emotionally defined bad investments set the stage for negative cognitions and
emotional frustrations. These cognitive and emotional factors (and untreated EF
deficits), in turn, further magnify problems with such cost–benefit analyses.
Consequently, there is an important mediating cognitive element for adults with
ADHD that affects these calculations of plans (intentions) and efforts to
reconcile them with individualsʼ values and goals (actions).

The Influence Matrix

The influence matrix (Henriques, 2011) extends behavioral investment theory to
the social world where most ADHD difficulties occur. The social context
represents its own commerce of social capital that affects human motivation,
emotion, behavior, and cognition. From an evolutionary view, the gamut of
social relationships and transactions are themselves resources and raw materials
for survival.
The ability to wield social capital, such as to influence others in accordance
with personal interests, is a key skill, which includes reciprocity and a balance
between generating and spending this capital. There are several distinct but
interrelated vectors of social influence. These include social rank in terms of
useful contributions that benefit the group; altruism, cooperation, and other
forms of self-sacrifice as means to build status and collateral with others; and
self-sufficiency, which is a balance between autonomy and interdependence,
being able to manage alone but still nurturing a standing with the group. Each of
these facets represent a relative ratio that is constantly recalibrated, including
striking the right balance of self-to-other-focus.
The relevance of the influence matrix is that the difficulties faced by adults
with ADHD have a social, public element to them. Adults with ADHD are prone
to inconsistency and poor follow-through on plans and promises, which have
ripple effects on social capital and social standing for self and others. The
interpersonal effects of poor follow-through often are described by adults with
ADHD in emotional terms of guilt and shame, and thoughts that others are
frustrated and disappointed with them, not to mention accounts of relationship
disruptions. These issues are relevant in CBT for adult ADHD, which focuses on
clientsʼ social functioning as well as the role of a strong therapeutic alliance that
provides a safe, supportive place to address these issues.

The Justification Hypothesis

The justification hypothesis is a framework for a meaning-making aspect of
cognition as self- and other-directed explanation of what happens and why it
happens. The hypothesis is that this idea proposes a structure and function of the
coevolution of self-consciousness and culture (Henriques, 2011). The evolution
of human consciousness provided humans with a distinct sense of a self apart
from others, the foundational EF (Barkley, 2016) providing a self to regulate.
The cognitive, narrating capacity to account for the what feature of events and
the associated causal why of events also includes the self and other justification
of an individualʼs actions or inactions. These internal dialogues have a private
component in terms of sense of self and identity and a public component of the
presentation and explanation of the self to others.
Considered through the lens of the justification hypothesis, cognitions serve
an explanatory function which, at least partly, can be viewed as justifications for
actions and inactions, consistent with facets of CBT (A. T. Beck, 1976; Dobson,
Poole, & Beck, 2018; see Chapter 3, this volume). This cognitive, explanatory
function ties together the behaviors to be explained (behavioral investment
theory), the explanations communicated to stakeholders in an individualʼs life to
maintain social standing (influence matrix), and the internal processing and
sense-making of events in the context of an individualʼs identity (or sense of
self) and other cognitive factors, including risk for cognitive distortions. In fact,
adults with ADHD often report being unable to make sense of their consistent
inconsistency themselves, much less being able to explain it to others (“How can
I ask the professor for another extension on the same assignment?”).
This review highlights the deep-seated nature of self-regulation and the
complex behavioral, social, and cognitive mechanisms that affect human
functioning. The effects of ADHD and EF deficits cut deeply through each of
these facets and, in turn, through the roles, relationships, and domains of life for
adults with ADHD in a persistent and wide-ranging manner. Although this
overview is a far cry from some of the typical clinical material encountered with
adults with ADHD (“Yes, very interesting for the early humans, but I cannot
find my keys and Iʼm already late for work”), these insights highlight the
recurring struggles and their effects on this population.

PREVALENCE, PERSISTENCE, AND COMORBIDITY AND

IMPAIRMENTS OF ADULT ADHD

As ADHD is a neurodevelopmental syndrome, there are many questions related

to its manifestation, appearance, and effects at different points along the
developmental trajectory. More specifically, it can be confusing to sort through
various reports on the numbers of individuals with ADHD in different age
groups and the degree to which children and adolescents grow out of it. From a
clinical standpoint, it is important to appreciate the complexity of coexisting
factors faced by clinic-referred adults with ADHD and the life problems they
face that necessitate treatment. Reviews of each of these factors are provided
below.

Prevalence of ADHD
The diagnostic prevalence for ADHD cited in the DSM–5 on the basis of expert
consensus derived from the literature is 5% of children and 2.5% of adults
(American Psychiatric Association, 2013). The international prevalence of
childhood ADHD is estimated at 6.5% (Polanczyk, de Lima, Horta, Biederman,
& Rohde, 2007).
Comprehensive surveys conducted in the United States and in international
samples provide corroborative support for DSM–5 prevalence rates. Adult
ADHD rates in the United States are 4.4% and among international samples
(Americas, Europe, and the Middle East) are 3.4% (Fayyad et al., 2007; Kessler
et al., 2006). A secondary analysis of the U.S. sample that examined adult
ADHD in the workforce yielded a prevalence of 4.2% (Kessler, Adler, Ames, et
al., 2005). These prevalence rates translate to about 8 to 10 million adults in the
United States are affected by ADHD. There are published reports of increased
rates of diagnosis, which are based on diverse ways in which a diagnosis was
determined, including health care providers simply stating a child or adolescent
had ADHD (Visser et al., 2014). These are important issues, but these
prevalence rates are generally accepted (Kooij et al., 2019).

Persistence of ADHD
Persistence rates of childhood ADHD into adulthood can range from 4% to 77%
depending on the manner in which ADHD is assessed in adulthood (Sibley,
Mitchell, & Becker, 2016). Most estimates of persistence fall around 50%,
though the persistence of residual symptoms that cause some form of functional
impairment often falls in the range of 65% to 85% (Barkley et al., 2008;
Biederman, Petty, Clarke, Lomedico, & Faraone, 2011; Biederman, Petty,
Evans, Small, & Faraone, 2010; Sibley et al., 2016; Volkow & Swanson, 2013).
A national comorbidity survey indicated that 36.3% of respondents who had met
DSM–IV (American Psychiatric Association, 1994) criteria for ADHD in
childhood continued to meet strict diagnostic criteria in adulthood on the basis of
self-report (Kessler, Adler, Barkley, et al., 2005). Because of limitations of
DSM–IV criteria for adults, namely the lack of EF items and age-of-onset
criterion of 7 years old at the time, this rate is likely an under estimation. A
review of studies indicated persistence rates as low as 4% when full diagnostic
criteria were used (including strict age-of-onset criterion). When defining
persistence as clinically significant symptoms of ADHD or partial remission,
rates were between 36% and 86% (Faraone et al., 2006).

Psychiatric Comorbidity, Functional Impairments, and Adult ADHD

Psychiatric comorbidity is the rule rather than the exception in clinic-referred
adults with ADHD. Upward of 80% of adults diagnosed with ADHD will have
at least one comorbid diagnosis (Barbaresi et al., 2013; Barkley et al., 2008;
Biederman et al., 2012; Brook, Brook, Zhang, Seltzer, & Finch, 2013; Faraone et
al., 2015; Kessler, Adler, Barkley, et al., 2005; Kessler et al., 2006; Klein et al.,
2012; Kooij et al., 2019).
The most common co-occurring disorders seen in adults with ADHD, in
descending order of prevalence, are anxiety, depression, and substance use
disorders (Barkley, 2015c; Kessler et al., 2006; see also Chapter 6, this volume).
Nicotine (cigarettes), alcohol, and marijuana are the most common substances of
abuse for adults with ADHD (Upadhyaya & Carpenter, 2008) with substance use
disorders occurring in ADHD samples at twice the rates seen in the general
population (Barkley, 2015c).
Adults with ADHD, compared with adults without ADHD, experience
academic difficulties (e.g., increased educational disruption and lower academic
attainment), occupational problems (e.g., lower levels of employment, more
frequent job changes, lower salaries, poorer job performance ratings),
relationship difficulties (e.g., lower relationship satisfaction, higher marital
discord), and higher risk for psychiatric and substance use diagnoses. There are
various other functional difficulties that affect health and well-being, such as
sleep problems, poorer driving records, financial difficulties, and higher rates of
injuries and various sexual and health risks, including unplanned pregnancy and
obesity (see Barbaresi et al., 2013; Barkley et al., 2008; Biederman et al., 2006;
Brook et al., 2013; Cortese, Faraone, Bernardi, Wang, & Blanco, 2013; Galéra et
al., 2012; Klein et al., 2012; Kooij et al., 2019; Nigg, 2013). Recent evidence
indicates that health and lifestyle patterns associated with a childhood history of
ADHD persisting into adulthood predicts shorter life expectancy (by up to 13
years) on the basis of actuarial calculations of health-related variables measured
at 27 years old (Barkley & Fischer, 2019).
There is virtually no area of adult life that is immune to the effects of ADHD.
Data on life impairments derived from longitudinal and cross-sectional studies
on adult ADHD land it near the top of the list of the most impairing conditions
seen in outpatient clinical psychology and psychiatry. It is likely that these life
frustrations and disruptions play a formative role in the common maladaptive
thoughts and beliefs held by adults with ADHD and other psychological effects.

Psychological Effects of ADHD

A lifetime diagnosis of ADHD has negative effects on sense of identity,
satisfaction, perceived life options, and self-esteem (Cook, Knight, Hume, &
Qureshi, 2014; Harpin, Mazzone, Raynaud, Kahle, & Hodgkins, 2016; Newark,
Elsässer, & Stieglitz, 2016). When recalling childhood and adolescent
experiences, adults with ADHD (compared with adults without ADHD) rated
themselves as less likely to have engaged in common academic, extracurricular,
social, and family activities (Biederman et al., 2006). Among adults with
ADHD, 72% reported that their symptoms have had lifelong effects on them and
endorsed current work and relationship impairments. Lastly, adults with ADHD
were significantly more negative in their outlooks on life and endorsed lower
ratings of self-acceptance than adults without ADHD.
A review of studies of self-esteem indicates that this is a significant
therapeutic factor for adults with ADHD (Cook et al., 2014). Self-esteem ratings
are inversely correlated with symptomatology and, in one study, with overall
psychological distress; there were no gender differences or differences by
ADHD presentation. Self-esteem may be a mediating factor between ADHD
symptoms and functioning in various life domains. It is increasingly clear that
ADHD has corrosive effects on functioning and sense of self.

CONCLUSION

The essence of ADHD as a problem of self-regulation, and what is so insidious

about its effects, is that it impairs and inhibits self-expression and self-
determination by repeatedly punctuating and fracturing an individualʼs sense of
agency—it unduly limits viable options for how adults with ADHD elect to
“spend themselves” in their lives. Indeed, although such endeavors can be
defined in behavioral, actionable, and achievable terms, the catalytic role of
outlooks, thoughts, and beliefs is necessary (but not sufficient) to turn intentions
into actions, as argued in the following chapters.
Although ADHD is among the conditions that cause the most impairment, it
is among the most treatable. The next chapter provides a brief review of
medication and psychosocial treatments, focused on outcome studies of CBT for
adult ADHD. Research on the relevance of cognitive distortions and maladaptive
schema in understanding ADHD is also presented.

KEY CLINICAL POINTS

The age-of-onset criteria for diagnosing adults with ADHD using

the DSM–5 has been adjusted to 12 years old and the symptom
threshold has been adjusted to require five of nine symptoms from
either domain; the 18 symptoms themselves are unchanged.
The contemporary view of ADHD is that it as a
neurodevelopmental disorder of impaired self-regulation. The
executive function model of ADHD provides a framework for
understanding the core difficulties associated with ADHD along with
closely aligned models of self-dysregulation (e.g., default mode
network), the role of dopamine and reward-deficiency, and findings
from genetic and neuroimaging research.
Various issues related to the self-dysregulation model of ADHD are
consistent with features of a unified theory of psychology
(Henriques, 2011). Specific facets of this model relate to nonconscious
factors that affect behavioral selection, factors that gain and wield social
capital, and the role of cognition as self- and other-justification for
action or inaction.
Rates of childhood ADHD fall at about 5% and rates of adult
ADHD at about 4%. About 66% of children with ADHD continue to
exhibit the full diagnosis into adulthood, though those with residual
symptoms may still have clinical difficulties. So called late-identified
adults who meet current criteria for ADHD are established
retrospectively with emergence in childhood but were not diagnosed in
childhood.
The coexistence of other conditions with ADHD is the rule rather
than the exception. Anxiety, depression, and substance use problems
(e.g., nicotine, alcohol, marijuana) are the most common coexisting
diagnoses
Studies of the impairments associated with a lifetime history of
ADHD indicate that they may occur in virtually any category of
adult functioning, most notably work, academics, relationships,
health and well-being, driving, and financial status, though there
are many others.
A lifetime history of ADHD also has potentially negative effects on
psychological functioning, including sense of identity, satisfaction
(past and present), perceived life options, and self-esteem.
2
Clinical Outcome Research for Adult
ADHD

Despite the wide-ranging impairments outlined in Chapter 1, adult ADHD is a

condition for which there are effective treatments. Cognitive behavior therapy
(CBT) is an evidence-supported psychosocial treatment for adult ADHD, often
provided in combination with medications. Emerging research has shed light on
the bearing of maladaptive cognitions and beliefs for this clinical population.
The goal of this chapter is to summarize the status of clinical outcome
research on CBT for adult ADHD. A brief overview of medications for adult
ADHD provides basic information on this important, often essential treatment
option. This review of CBT also summarizes the extant outcome research and
highlights recent novel studies. Finally, current research on cognitions and
beliefs and adult ADHD are presented, which will set the stage for discussions of
the adapted CBT model for adult ADHD and interventions in the following
chapters.

TREATMENTS FOR ADULT ADHD

ADHD has potentially wide-ranging effects on most domains of life. The

severity of symptoms and impairments can range from mild and circumscribed
to severe and pervasive with a range of complicating factors. To date,
medications and CBT are the two most established treatment options for adults
with ADHD. These treatments are reviewed next with summaries of outcome
research supporting their efficacy.

Medications
Pharmacotherapy is a first line of treatment for ADHD symptoms across all age
groups, most notably the use of stimulant medications (e.g., methylphenidate or
amphetamine-based compounds) but also many effective nonstimulant
preparations (e.g., atomoxetine, guanfacine, clonidine). The most frequently
prescribed and effective class of medications in the treatment of ADHD is
psychostimulants. Various reviews of the efficacy and effectiveness of
medications for ADHD indicate that stimulant medications (short- and long-
acting preparations) achieve large effect sizes (Cortese et al., 2018; Faraone et
al., 2015; Kooij et al., 2019; Prince, Wilens, Spencer, & Biederman, 2015).
These medications are associated with symptom improvements; methylphenidate
for children and adolescents and amphetamines for adults have emerged as the
most effective options, respectively (Cortese et al., 2018). Stimulants as a group
are generally well-tolerated and safe when taken as prescribed.
There are nonstimulant medications approved for individuals with ADHD,
which can be used straightaway as first-line agents when indicated (e.g., cases of
past stimulant misuse or abuse) to augment already prescribed stimulants or as
backup options in cases when clients do not respond to or cannot tolerate
stimulants (Cortese et al., 2018; Prince et al., 2015). These medications, the most
noted of which is atomoxetine, have demonstrated moderate effect sizes in
reducing core symptoms.
A benefit of stimulants is that when taken as prescribed and active in
individualsʼ systems, clients will experience positive therapeutic effects. A
combination of long- and short-acting preparations is sometimes used to extend
coverage, as in the case of a college student with ADHD who needs to focus in
class during the day and on studying in the evening. A benefit of nonstimulant
medications is that they can be taken daily and provide 24-hour symptom
coverage.
A range of FDA-approved medications is available for treating symptoms of
ADHD and can provide options to clients who do not respond to a particular
medication. There are medications that have been found to be helpful in treating
adult ADHD but that are FDA-approved for other conditions. For example,
bupropion is a viable option in cases of concurrent ADHD and depressed mood.
These medications can be prescribed as off-label treatments and have often
produced positive results in studies of adult ADHD. In cases of increasing
clinical complexity, such as coexisting mood and anxiety disorders, multiple
medications may be prescribed to address diverse symptom clusters. Adequate
treatment of ADHD symptoms often improves concurrent mood and anxiety, as
ADHD-related stressors may have triggered these symptoms in the first place.
Despite impressive outcomes and effect sizes, not every adult with ADHD
will respond to medications or experience improved functioning with
medications alone. Some adults with ADHD experience intolerable side effects,
have a partial response with persistent residual symptoms, or might simply not
respond to medication. In rare cases, there may be medical conditions, risks, or
other factors (e.g., during pregnancy or while breastfeeding) that obviate the use
of medications.
Medications are a “broad-band” treatment for ADHD (Faraone & Antshel,
2014), which means they target core symptoms and in doing so also improve
functioning as an added benefit. For this reason, medications alone are a
sufficiently effective treatment for many adults with ADHD. Medications are not
as effective at treating executive function and motivational deficits as they are at
treating core symptoms (Biederman et al., 2015). Symptom reduction does not
inexorably translate into real-world gains, such as tackling disorganization,
procrastination, or managing diverse adult roles (e.g., “the skills are not in the
pills”). In fact, adults with ADHD very often will need some sort of adjunctive
psychosocial treatment, ADHD coaching, or academic support to address
difficulties in specific life domains. The next section reviews the research on
CBT for adult ADHD. Other nonpharmacological options for adult ADHD vary
in terms of the availability and quality of empirical evidence for their efficacy
but that are beyond the focus of this book and have been reviewed elsewhere
(see De Crescenzo, Cortese, Adamo, & Janiri, 2017; Faraone & Antshel, 2014;
Ramsay, 2010b).

Summary of Cognitive Behavior Therapy for Adult ADHD: Clinical Studies

and Manuals
CBT emerged as a logical choice for a psychosocial approach for adult ADHD
on the basis of its session structure and emphasis on problem-solving, activity
scheduling, graded tasks, and other skills relevant to ADHD (Ramsay, 2010b).
An all-too-brief synopsis of CBT as a model of psychotherapy is that it focuses
on the interplay of cognitions, behaviors, and emotions in understanding
psychiatric disorders, with an emphasis on cognitions (thoughts, images, beliefs)
in the change process (A. T. Beck, 1976). It is based on a cognitive model of
psychopathology and highlights the role of information processing (e.g.,
cognitions) on the development and maintenance of psychiatric disorders as well
as on other aspects of human functioning (J. S. Beck, 2011; Dobson, Poole, &
Beck, 2018). The clinical application of CBT involves helping clients to
recognize, evaluate, and modify their existing cognitive and behavioral patterns
to promote improved functioning and well-being. Chapter 3 of this book
provides a detailed review of the cognitive model and its adaptation to adult
ADHD.
Initial psychosocial approaches for adult ADHD were arrived at by
independent groups of clinician–researchers. Most, if not all, of these early
approaches fell under the umbrella of being CBT-oriented with descriptors like
“thoughts-feelings-actions” or “cognitive remediation,” but all were adapted to
address ADHD (see Knouse, 2015; Ramsay, 2010b, 2011a; Ramsay & Rostain,
2015b). Clinical outcome studies on CBT for adult ADHD emerged in the late
1990s and early 2000s and have grown exponentially, including recent
randomized controlled trials that compared CBT with active treatments (e.g.,
relaxation training) and with standard community care (e.g., treatment-as-usual
[TAU], nonspecialized community counseling).
The research basis of CBT for adult ADHD ranges from open studies to
randomized controlled trials (for reviews, see Knouse, 2015; Knouse & Safren,
2010; Manos, 2013; Mongia & Hechtman, 2012; Ramsay, 2010b, 2011a;
Ramsay & Rostain, 2015b) and evaluation by meta-analyses (see De Crescenzo
et al., 2017; Jensen, Amdisen, Jørgensen, & Arnfred, 2016; Knouse, Teller, &
Brooks, 2017; Lopez et al., 2018; López-Pinar, Martínez-Sanchís, Carbonell-
Vayá, Fenollar-Cortés, & Sánchez-Meca, 2018; Moriyama, Polanczyk, Terzi,
Faria, & Rohde, 2013). Published case studies provide additional clinical
guidance for these approaches (Mitchell, Nelson-Gray, & Anastopoulos, 2008;
Puente & Mitchell, 2016; Ramsay, 2011a, 2012, 2016b; Ramsay & Rostain,
2005b, 2008, 2015b; Rosenfield, Ramsay, & Rostain, 2008; Willer, 2017).
Overall, results indicate that (individual and group) CBT is associated with
significant improvements on measures of ADHD symptoms and other common
features with baseline scores compared with results at end of treatment and at
follow-up. The outcome measures are based on self-report, other report (in some
studies), and increasingly on blind ratings. Effect sizes generally fall in the
moderate to large range (Jensen et al., 2016; Knouse et al., 2017; Lopez et al.,
2018; Manos, 2013). Most but not all studies also report improvements on
measures of comorbid conditions and other factors (e.g., self-esteem).
A recent critique of outcome studies (Lopez et al., 2018) concluded that there
is evidence that CBT for adult ADHD is beneficial in the short term, but the
evidence is “low quality.” Of the studies reviewed, clinician-rated and self-
reported core symptom improvements ranged in effect size from −0.16 to −1.22.
The relative lack of follow-up data, the heterogeneity of outcome measures, and
the restricted geographical location of extant studies are cited as limitations on
the generalizability of results. Across reviews and meta-analyses, the stricter the
experimental controls (use of blind ratings, active control treatments), the lower
the reported effect sizes.
There has been an increase in well-designed randomized controlled studies,
including those that compared manualized CBT protocols for ADHD with active
control treatments, such as relaxation training (Safren et al., 2010), computerized
cognitive training (Virta et al., 2010), supportive group therapy (group validation
and psychoeducation; Solanto et al., 2010), and psychoeducation (Vidal et al.,
2013). In three of these studies (Safren et al., 2010; Solanto et al., 2010; Virta et
al., 2010), treatments for ADHD achieved better outcomes than the active
control treatments, though some active control treatments also achieved gains
from baseline. The Vidal et al. (2013) study comparing a psychoeducation group
and a CBT group for adult ADHD indicated that both produced improvements
from baseline but with no difference between groups.
When comparing participants either on or off of prescribed ADHD
medications during these trials, there are no significant differences in treatment
response on the basis of medication status; it should be cautioned, though, that
participants who were not taking medications likely had milder, more
circumscribed symptoms and impairments. Practicing therapists will often be
asked by clients whether they should try medications first, CBT first, or both.
There may be logistical factors behind clientsʼ inquiries such as whether
therapists accept insurance and the availability of nearby therapists able and
willing to treat ADHD. The case for concurrent CBT and pharmacotherapy with
research supporting this view is presented below. However, such questions may
reflect lack of knowledge about options or ambivalence or reticence for some
clients. Psychoeducation about different approaches and addressing misgivings
can help clients make informed decisions. Therapists can emphasize that it is not
a one-off, irrevocable treatment decision. If someone starts with medications but
finds more help is needed to address functioning, an adjunctive treatment can be
added and vice versa. Some recent studies have prospectively examined
response to CBT by adults with ADHD either on or off medications.
Philipsen and colleagues (2015) conducted the largest ever treatment study of
adult ADHD. This multisite study compared 1 year of concurrent psychosocial
and medication treatments for ADHD with the specialized treatment for ADHD
being group dialectical behavior therapy (DBT; Linehan, 1993) adapted for adult
ADHD (Hesslinger, Philipsen, & Richter, 2004). A sample of 419 German
adults with ADHD were randomly assigned to either methylphenidate or placebo
within the medication arm of the study; and to either specialized group DBT or
individual clinical management within the psychosocial arm. Psychosocial
treatment consisted of 12 weekly sessions, then monthly follow-up visits.
After 3 months of treatment and at the 1-year endpoint, medication
outperformed placebo, and surprisingly, there were no differences between
group DBT and individual clinical management, which both achieved better
outcomes when combined with medications (versus placebo). These findings
recall those obtained in the MTA study of 579 children with ADHD (7–9.9 years
old) randomized to behavior therapy, medications, or combined treatment (MTA
Cooperative Group, 1999), in which medications alone and combined treatment
achieved the best outcomes (although ongoing follow-up analyses provided
more clinically nuanced results).
More recently, Groß and colleagues (2019) compared participant self-ratings
on the benefits of the respective psychosocial treatments within the larger study
reviewed above (Philipsen et al., 2015). Significantly, though moderately more
participants rated the DBT group as more helpful than individual clinical
management at the end of treatment. At 6-month follow-up, this difference only
emerged for those on placebo who received either of the psychosocial
treatments; there was no difference between DBT+placebo and individual
clinical management+stimulant with DBT group therapists rated as the most
helpful treatment component.
A conjecture about the surprising results in the larger study is that although
group DBT was tailored to adult ADHD and had achieved positive results in
previous studies, the control TAU was individual- rather than group-
administered. The personalization of individual treatment, even if not
specialized, may provide some differential benefit, though this is speculation.
A randomized controlled study (Cherkasova et al., 2016) of adults with
ADHD compared those who completed a 12-session course of CBT while either
on an established medication regimen for ADHD or unmedicated. The
CBT+medication group achieved significantly better outcomes at the end of
treatment than the CBT-only group. However, the CBT-only group showed
continued gains at posttreatment follow-up assessments whereas the
CBT+medication groupʼs gains were maintained. The CBT-only group “caught
up” by the 3- and 6-month follow-up, at which times were no significant group
differences in outcomes.
Another novel study examined 10 adults with ADHD who completed a 12-
session course of manualized CBT (Safren, Perlman, et al., 2005) compared with
12 matched, healthy control participants on resting-state functional magnetic
resonance imaging (r-fMRI) scans at pre- and posttreatment (Wang et al., 2016).
In addition to the predicted improvements achieved by adults with ADHD on an
ADHD symptom measure, there was a post-CBT increase on the functional
connectivity strength in the frontoparietal network and cerebellar regions as
measured by r-fMRI. These brain regions are the same in which effects occur in
studies of ADHD medications, suggesting a common brain mechanism, though
not reaching a point of normalization in this study (Q. Cao, personal
communication, October 6, 2018).
Some CBT approaches, although consisting of the same intervention domains
and coping skills as modularized approaches, adapt a case conceptualization or
problem-focused approach, and tailor strategies to the presentation of each client
(Ramsay & Rostain, 2011; Rostain & Ramsay, 2006; Weiss et al., 2012). A
recent randomized study compared such an approach for adult ADHD with TAU
(Dittner, Hodsoll, Rimes, Russell, & Chalder, 2018). Results indicated that the
conceptualization approach achieved significantly greater improvements than
TAU, with strong effect sizes on symptom, functioning, and secondary symptom
measures.
Results from clinical outcome studies have produced mostly moderate-to-
strong effect sizes, which places CBT for adult ADHD alongside medications as
an evidence-supported treatment for adult ADHD. CBT for adult ADHD is
considered to have “strong” research support as set out by the Society of Clinical
Psychology (Division 12 of the American Psychological Association; Emilsson
et al., 2011; Safren, Otto, et al., 2005; Safren et al., 2010; Solanto et al., 2010).
Whereas medications are a broad-band treatment for ADHD, CBT is a “narrow
band” treatment (Faraone & Antshel, 2014) that targets a specific subset of
symptoms, behaviors, or impairments.
There are several manualized, English-language CBT programs for adult
ADHD to guide practicing clinicians, including a few with companion client
workbooks or materials (see Ramsay & Rostain, 2015a, 2015b; Safren, Sprich,
Perlman, & Otto, 2017a, 2017b; Solanto, 2011; S. Young & Bramham, 2012).
Manualized approaches also are available in German, Swedish, and Finnish
(Hesslinger et al., 2004, 2010; Hirvikoski, Waaler, Carlsson, Helldén, &
Lindström, 2013a, 2013b; Leskelä et al., 2007; Virta et al., 2009). All of them
have been the subject of some degree of outcome research.
To date, outcome studies have been based on treatment packages. There have
been reviews of proposed mechanisms of action and essential therapeutic
components of these packages (Knouse, 2015; Knouse & Safren, 2010; Ramsay,
2010a) and potential side effects (Knouse & Ramsay, 2018); dismantling studies
of these mechanisms or identifying empirically supported principles of change
(Rosen & Davison, 2003) have not yet been conducted. There is a consensus for
the requisite coping skills for managing ADHD and its features: time
management skills, use of a daily planner, organizational skills, strategies for
breaking down tasks, dealing with procrastination, self-esteem, stress and
emotions, and psychoeducation about the effects of ADHD.
A point of discussion has been the relative bearing of cognitive interventions
within CBT for adult ADHD. It is the consistent use of the essential coping skills
that is deemed the key mechanism of change in CBT for adult ADHD (Knouse,
2015; Knouse & Safren, 2010). This behavioral focus rightly targets the areas of
impairment for which individuals seeks treatment. Maladaptive thinking does
not play a causal role in the ADHD syndrome and its characteristic symptoms
and self-regulation deficits.
Seeing ADHD as a performance or implementation problem (Ramsay &
Rostain, 2016a), it makes sense that the central emphasis in CBT is on the use of
the prescribed coping strategies in real-world roles and settings. Used
consistently, these strategies will lead to improved functioning and well-being,
which is the ultimate target and measure of its effectiveness. Thus, in terms of
the relative ratio of constituent interventions in its moniker, CBT for adult
ADHD could be represented by a lowercase c and an uppercase B (Ramsay,
2017b; Ramsay & Rostain, 2016a).
 Emerging research reveals a somewhat different, though still important role
cognitions play in adult ADHD when compared with more traditional disorders
targeted by CBT. This research may shed new light on ways that CBT must be
adapted to the unique needs of adults with ADHD.

RESEARCH RELEVANT TO THE COGNITIVE BEHAVIOR THERAPY

MODEL OF ADULT ADHD

The studies reviewed next provide a justification for the continued use of an
uppercase C in CBT for adult ADHD and the role of cognition in the functioning
of adults with ADHD. Collectively, these studies illustrate the mediating role of
cognitions in the life problems faced by adults with ADHD and how these mind-
sets interfere with coping, which dictates cognitive interventions adapted to this
clinical group.

Negative Thinking in Childhood and Adolescent ADHD

The psychosocial treatments for ADHD in children and teenagers are mostly
behavioral, focused on parent- and teacher-training, school–home
communication, and modifying the environment. Upward extensions of
childhood treatments for ADHD in teenagers generally have not been found to
be effective, though there are novel programs for middle- and high-school
students with ADHD (Langberg et al., 2018; Sibley et al., 2014); downward
extensions of CBT for adult ADHD adapted for use with teenagers have yielded
initial positive results (Antshel & Olszewski, 2014; Sprich, Burbridge, Lerner, &
Safren, 2015). There are studies of negative thinking in children and adolescents
with ADHD that are relevant to adults.
A prospective study comparing children with ADHD on a measure of
negative thoughts found that children with the combined presentation endorsed
more themes of failure and hostile intent than those with the inattentive
presentation (Castagna, Calamia, & Davis III, 2017). The findings were
moderated by anxiety, as children with the combined presentation and anxiety
endorsed the highest level of negative thoughts.
Most individuals with ADHD struggle at work, so the vocational identities of
high school students with ADHD were examined, including a measure of career
thoughts and attitudes (Dipeolu, Sniatecki, Storlie, & Hargrave, 2013). Students
with ADHD endorsed higher dysfunctional attitudes and lower career readiness,
which predicted their significantly below average vocational identities compared
with scale norms.
Retrospective accounts of childhood and adolescent experiences were
obtained in a telephone survey of adults endorsing ADHD and compared with
those of adults without ADHD (Biederman et al., 2006). When rating their
current outlooks, adults with ADHD endorsed significantly lower levels of self-
acceptance, were less likely to describe their futures as bright, and were more
likely to endorse angry, negative thoughts; dysphoria; impulsivity; and social
mistakes.
When recalling their experiences as school-age children, the adult ADHD
group reported significantly fewer educational/cultural activities outside of
school, less connection with the community, fewer hobbies or extracurricular
activities, and less free time spent with family and friends. Their responses
indicated a lowered sense of preparedness for adult life and that their
developmental experiences were worse than their peersʼ experiences, which
were endorsed as having continued negative effects on their outlooks.
With ongoing cognitive development, children start to make sense of the
world and their personalized rules for navigating through it. These outlooks
consolidate during adolescence and have greater influence on their reciprocal
exchanges with various settings, people, and roles they assume. The next section
reviews the studies on cognitions in adults with ADHD.

Studies on Cognitive Distortions and Adult ADHD

Only recently have investigators specifically targeted cognitive distortions and
maladaptive beliefs in adults with ADHD. Negative attitudes and beliefs could
be discerned from previous longitudinal and outcome studies that included
various measures of self-perception and self-esteem. However, dysfunctional
thoughts and beliefs in adults with ADHD have been the chief focus of recent
studies.
Measures of dysfunctional beliefs and coping style were collected from a
sample of adults with ADHD to assess the relative contribution of cognitions and
behavioral coping style to coexisting depressed mood (Knouse, Zvorsky, &
Safren, 2013). Dysfunctional attitudes and cognitive-behavioral avoidance were
each found to make a unique and overlapping contribution to depression.
Negative thoughts and avoidance in adults with ADHD partially mediated each
other for the number of depressive symptoms endorsed and full depression
diagnoses.
These findings are consistent with clinically derived conceptualizations of
adult ADHD and negative outlooks as cognitive behavioral factors create a
vicious cycle (Knouse et al., 2013). The experience of living with ADHD
increases the likelihood that adults with this condition will face more failure
experiences than adults without the condition; in turn, these failure experiences
engender negative schemas (or patterns of thought) and create an expectation of
failure that promotes preemptive avoidance of endeavors seen as risks for
failure. This avoidance interferes with various life pursuits and creates more
disappointments, which reinforces failure schemas; it is an insidious, cyclical
pattern worsened by depressive symptoms.
A separate study examined the interaction of cognitive, behavioral, and
emotional factors in coping styles in adults with ADHD (Torrente et al., 2014).
These adults were compared with clinical (but non-ADHD) and nonclinical
control participants on measures of ADHD symptoms, dysfunctional thoughts,
mood and anxiety, and life impairment. The adult ADHD group endorsed higher
ratings of dysfunctional thoughts than did the nonclinical group and were on par
with ratings by the clinical group, suggesting that dysfunctional cognitions are
relevant in adult ADHD and commensurate with the degree seen in other
diagnoses. Dysfunctional thoughts were strongly associated with emotionality
for adults with ADHD. The combination of ADHD symptoms, dysfunctional
thoughts, and emotionality predicted life impairments.
 Considering the high coexistence rates of adult ADHD, depression, and
anxiety (including subthreshold presentations), and the role of emotional
dyscontrol as an aspect of ADHD (Barkley, 2015b), therapists specializing in
adult ADHD consider these studies to support the CBT model (e.g., the
interaction of ADHD and its role in life frustrations, subsequent outlooks, the
need for adapted cognitive interventions in treatment). A case could be made,
though, that the dysfunctional cognitions in these studies result from coexisting
mood and anxiety issues and are not specific to ADHD. To address this point,
studies have examined cognitions in adults with ADHD with and without
coexisting mood and anxiety factors or when controlling for these factors.
Young adults with ADHD but without comorbidities were compared with
nonclinical control participants on a measure of distressing thoughts
(Abramovitch & Schweiger, 2009). The ADHD group endorsed significantly
higher ratings on measures of intrusive and worrisome thoughts when compared
with the control group. The two most discriminating factors between the groups
were the frequency of worrisome thoughts and removal difficulty. Young adults
with ADHD in this sample exhibited difficulties inhibiting intrusive thoughts
and had more difficulties refocusing on more adaptive thoughts—their negative
thoughts were more virulent, taking hold more readily, and were tougher to
modify, or “stickier,” once taking root.
Another study involved two groups of adults diagnosed with ADHD (a group
with comorbid depression and a group without depression) and a nonclinical
control group (Mitchell, Benson, Knouse, Kimbrel, & Anastopoulos, 2013). The
three groups were compared on measures of negative thinking. Unsurprisingly,
the ADHD+depression group endorsed the highest level of negative thinking; the
results were significantly higher than either of the other two groups. However,
the adult ADHD without depression group endorsed significantly higher levels
of negative thinking than the nonclinical control group. This result provides
initial evidence of the presence and relevance of distorted thoughts in cases of a
primary diagnosis of ADHD, at least without depression.
Similarly, a chart review study was conducted on a sample of clinic-referred
adults with ADHD who completed measures of ADHD symptoms, depression,
anxiety, and cognitive distortions in the evaluation process (Strohmeier,
Rosenfield, DiTomasso, & Ramsay, 2016). There was a statistically significant
positive, low correlation of cognitive distortions and ADHD symptoms when
controlling for mood and anxiety, providing further evidence of a direct
connection of ADHD and negative thoughts.
However, the connection of ADHD, impairments, comorbidities, and
negative thinking is a complex one. A similar chart review study of these factors
in a sample of adults with ADHD (Serine et al., 2019) indicated that ADHD was
highly and positively associated with depression ratings and the Big Five
personality factor of neuroticism and negatively associated with the Big Five
personality factor of conscientiousness, which is consistent with previous
research on ADHD and personality (see Ramsay, Rosenfield, & Harris, 2011, for
a review). Anxiety was not significant, which is inconsistent with past research.
However, anxiety was measured by the Beck Anxiety Inventory (A. T. Beck &
Steer, 1990), which includes many somatic symptoms and may underestimate
the degree of worry and apprehension. Depression and neuroticism were the
factors most predictive of cognitive distortions, which is consistent with findings
in non-ADHD clinical populations.
Although comorbidities emerged as the seeming culprit for cognitive
distortions, comorbidities are not necessarily distinct from the unique aspects of
ADHD. Instead, the conceptual pathway outlined in CBT models of adult
ADHD is that this group is vulnerable to persistent distress and impairment from
the core features of ADHD. This distress and impairment dispose them to failure
experiences and related cognitive-behavioral avoidance that coalesce into
negative attitudes and beliefs, which further magnify impairments via increased
disengagement. These factors recursively magnify and are magnified by one
another (Knouse et al., 2013; Ramsay & Rostain, 2015b; Safren et al., 2017b;
Solanto, 2011; S. Young & Bramham, 2012).
Results from a longitudinal study of college students with ADHD who were
tracked for an academic year provided support for such ADHD-mediated
pathways (Eddy et al., 2015). The findings indicated that negative self-concept
and depression fully mediated the association between past academic
functioning and self-report of overall functioning at follow-up. Negative self-
concept was an important precursor to depression, which itself originated from
the experience of living with ADHD. What is more, in a separate study, adults
who have extensive treatment histories for ADHD endorse lower levels of
ruminative thinking patterns and report less cognitive-behavioral avoidance.
This less ruminative, less avoidant group was more resilient to an
ADHD+depression comorbidity than adults with ADHD without these protective
factors (Oddo, Knouse, Surman, & Safren, 2018).
This section has been dominated by “negative” terminology of dysfunctional
and maladaptive thoughts, which connotes a view of negativity and undue
pessimism. Such language plays a specific conceptual role in understanding and
communicating constructs. However, it should be noted that positive thoughts
can also be distorted, maladaptive, and unhelpful (e.g., gamblers who ignore the
laws of statistical probability).
The ADHD Cognitions Scale (ACS; Knouse, Mitchell, Kimbrel, &
Anastopoulos, 2019) is a seven-item, self-report scale scored on a 5-point Likert
scale that focuses on “incautious optimism” (Knouse & Mitchell, 2015) or
maladaptive positive thinking that gives rise to avoidance. The ACS exhibited
good reliability, factor structure, and validity across two community samples.
Inventories used to measure cognitions in the studies reviewed thus far used
conventional measures of maladaptive thoughts that may not capture the unique
thought processes of adults with ADHD. Thus, the ACS makes a unique and
important contribution to the study and assessment of cognitions in adult ADHD.
The incautiously optimistic, positive thoughts that compose the ACS are highly
correlated with measures of negative thoughts, which show that the central idea
for cognitive interventions is to foster adaptive, flexible thinking.
Although not a traditional study of cognitions, Guntuku, Ramsay, Merchant,
and Ungar (2019) examined social media posts on Twitter by 1,399 adults who
self-identified with ADHD. When compared with posts by matched control
participants, tweets by the adults with ADHD indicated personality factors that
were significantly more open and less agreeable. Linguistic analysis of word use
in tweets by adults with ADHD indicated significantly more negation, hedging-
uncertainty, intention-failure themes, and lower self-efficacy. Thematic analysis
showed more prominent themes of emotionality; self-criticism; substance use;
and mental, physical, and emotional exhaustion. Although not capturing
distortions per se, the results provide accounts of life with ADHD and cognitive
themes.
A component of the traditional CBT model is the connection of distorted
automatic thoughts with underlying maladaptive schemas and core beliefs.
Recent preliminary research has started to uncover the relevance of these deeper
cognitive domains and themes in the experience of adults with ADHD.

Studies on Early Maladaptive Schemas and Adult ADHD

Recent studies have examined maladaptive schemas suspected to arise from the
common, long-standing difficulties faced by clinic-referred adults with ADHD.
Covered in detail in Chapter 3, schemas represent mental categories for
assessing, interpreting, and consequently storing information from experience
for future use. This is an adaptive capacity, though developmental stressors may
result in beliefs that are maladaptive (unhelpful, distorted, or inflexible outlooks;
J. E. Young, 1999).
Miklósi, Máté, Somogyi, and Szabó (2016) administered a screening measure
for adult ADHD to a nonclinical group of adults. Of this sample, 7.4% screened
positive for ADHD (approximating established prevalence rates); the remainder
of the sample served as the control group. All participants completed the Young
Schema Questionnaire (J. E. Young, 1999), a measure of early maladaptive
schemas (EMS). A clinically derived subset of schemas was selected for the
study: social isolation, defectiveness/shame, failure, and insufficient self-
control/self-discipline. Measures of perceived stress and emotional well-being
were also obtained.
The participants with ADHD endorsed significantly higher ratings on all four
schema categories and total EMS score, with moderate effect sizes for each
category and a large effect size for total EMS. More ADHD symptoms, even in
this nonclinical screening sample, were associated with higher levels of
perceived stress and lower levels of emotional well-being. There were two
identified pathways linking ADHD symptoms and emotional well-being: (a)
severity of ADHD symptoms was associated with more stress leading to reduced
well-being and (b) a strong association of the severity of ADHD symptoms and
EMS resulted in higher perceived stress.
Philipsen et al. (2017) used the Young Schema Questionnaire in a clinical
sample of adults with ADHD whose diagnosis had been established by thorough
evaluations. The ADHD group was compared with a non-ADHD control group.
Most participants in the ADHD group (89.7%) had at least one coexisting
psychiatric diagnosis. The ADHD group had significantly higher mean scores on
18 of 19 schema domains. Large effects sizes were obtained for the following
EMS (in descending order): failure, defectiveness/shame, emotional deprivation,
subjugation, mistrust/abuse, negativity, and dependence/incompetence. These
results were deemed consistent with the low self-esteem and feelings of shame
commonly observed in clinic-referred adults with ADHD, which suggest that
such schemas are an important aspect of psychosocial treatment for adult ADHD
(Lücke, Lam, Müller, & Philipsen, 2017).
The issue likely driving these schemas and other maladaptive cognitions is
that adults with ADHD have repeatedly experienced a frustrated sense of cause-
and-effect because of punctuated follow-through on valued endeavors. The core
features of ADHD play a direct and causal role in various setbacks and
“failures” that thereby manifest in the form of self-doubts, maladaptive schemas,
and other negative thoughts that magnify (and are magnified by) existing self-
regulation deficits inherent in ADHD.
An early trade book on adult ADHD was titled You Mean Iʼm Not Lazy,
Stupid, or Crazy? (Kelly & Ramundo, 1993). The reason this title resonates with
readers is that it captures the self-attributions of so many adults with ADHD.
The self-reproaching, trait-based view in the title mimics the conclusion arrived
at by many adults with ADHD in the wake of innumerable, confounding
setbacks in the pursuit of viable goals—“Iʼm the common factor; Iʼm the
problem.”
In fact, an accurate diagnosis is the first cognitive intervention in CBT for
adult ADHD because it provides a new frame for understanding the problems
that had previously been moral failings (Ramsay & Rostain, 2015b). This
cognitive shift also provides genuine hope for change. However, ADHD is not a
knowledge deficit, and simply knowing what to do to change is not enough.
Cognitive change in a broad sense is an essential go-between in the process of
transforming behavior goals into behavior change, turning intentions into
actions, and implementing the coping skills for managing adult ADHD.

CONCLUSION

This chapter provided a synopsis of the current state of clinical outcome research
for adult ADHD, including CBT, and its standing as an evidence-supported
psychosocial treatment for adults with ADHD. Recent research has examined
with greater specificity the role of maladaptive thoughts and schemas, providing
support for the existing CBT for adult ADHD approach. The next chapter will
review the current CBT model for adult ADHD. This model is compared with
the CBT case conceptualization, which also serves as a synopsis of the generic
CBT model for psychopathology. The emphasis is on how the model has been
adapted to the needs of adults with ADHD, including a proposed central
cognitive theme for adult ADHD.

KEY CLINICAL POINTS

Medications are an effective, evidence-supported treatment for

individuals with ADHD of all ages. Psychostimulants are the most
effective, with amphetamine-based compounds most effective for
adults. Medications are a broad-band treatment, meaning that they target
symptoms and improve functioning, though many adults with ADHD
may have functional difficulties despite symptom improvements.
There are a growing number of clinical outcome studies of CBT for
adult ADHD, including increasingly rigorous designs. As a group,
these studies have indicated positive outcomes with moderate-to-strong
effect sizes.
CBT is a narrow-band treatment that targets impairments by
fostering the consistent use of self-regulatory coping skills.
Recent research into maladaptive cognitions and schemas has
provided support for the cognitive domain of adult ADHD. There is
evidence of negative thinking in children, high school students, and
retrospective accounts of adults with ADHD of lower self-acceptance
and more negative outlooks about their future.
Studies of adults with ADHD indicate that they endorse more
cognitive distortions than control participants in cases of comorbid
depression, uncomplicated ADHD, and when controlling for
comorbidities. There is also evidence that adults with ADHD endorse
more maladaptive schema domains and at a greater severity level.
3
Cognitive Behavior Therapy Model of
Adult ADHD

This chapter presents a cognitive behavior therapy (CBT) model adapted to

adult attention-deficit/hyperactivity disorder (ADHD), including a proposed
central cognitive theme derived from this model. This theoretical review takes
the research on maladaptive cognitions and schemas (discussed in Chapter 2)
and the contemporary view of ADHD as a neurodevelopmental disorder of
impaired self-regulation (discussed in Chapter 1) and integrates them using the
CBT model for conceptualization and psychosocial treatment of adults with
ADHD. Adaptations of the basic model are necessary to meet the needs of
clinic-referred adults with ADHD, which are important for the clinical
interventions that comprise the remaining chapters of this book.
This chapter starts with the introduction of the CBT case conceptualization,
which represents a clinically geared synopsis of the fundamental elements of the
basic CBT model (J. S. Beck, 2011; Dobson, Poole, & Beck, 2018). The
conceptualization provides a blueprint for understanding clientsʼ presenting
difficulties and a corresponding guide for change. This review sets the stage for
a narrowed focus on the generic cognitive model (GCM) of psychopathology,
which emphasizes the cognitive domain (i.e., the C in CBT). The review targets
the elements of the GCM most relevant to adult ADHD as they require some
customization to better fit the unique features of ADHD. A proposed CBT model
for adult ADHD is then discussed, including the basic premises about ADHD in
adults on which this model is based and the premises of the CBT approach for
adult ADHD that guides interventions outlined in the remaining chapters of this
book.

COGNITIVE BEHAVIOR THERAPY CASE CONCEPTUALIZATION

The CBT case conceptualization is a framework used to organize and understand

the difficulties for which clients seek help (J. S. Beck, 2011; Dobson et al.,
2018). It includes developmental experiences and how these influence
cognitions, emotions, and behaviors associated with existing problems. This
conceptual scaffold helps clinicians to think like a CBT therapist (Wenzel, 2019)
and assimilate and make sense of new information, including the effects of past
experiences.
Key developmental experiences are important because these life events and
lessons are the raw materials from which people make sense of their world and
form the rules, schemas, and beliefs needed to navigate it. These developmental
experiences can run the gamut from powerful, stand-alone events to protracted
ones and from healthy, positive events to those with adverse, traumatic effects. It
is how these events are viewed, felt, and encoded in a clientʼs meaning-making
system that is relevant to CBT.
Developmental experiences, particularly those childhood events that are
associated with strong emotions, form deep, visceral beliefs and rules about how
the world is constructed, which color the lenses through which an individual sees
the world. These deep beliefs are defined as the schemas and core beliefs.
Although often used interchangeably, schemas are mental structures or
categories for assessing, interpreting, and storing information from past
experiences for future use (Dobson et al., 2018). This meaning-making
propensity is adaptive because it allows experiences to be catalogued for future
use rather than relying on trial-and-error learning. Schemas that are adaptive in
one context can be maladaptive in others. It is this dissonance that leads to
functional difficulties and distress. Core beliefs are the personalized expressions
of generic schemas that form an individualʼs personal rules for life. These
nonconscious beliefs, rules, and schemas are often revealed from clientsʼ
descriptions of thoughts that seem to cluster around recurring themes (Wenzel,
2019).
Ultimately, these schemas and core beliefs guide an individualʼs outlook on
and functioning in various roles, situations, and relationships across time and
settings. There are many adaptive and helpful beliefs that promote good
functioning and healthy responses to situations. Maladaptive schemas and core
beliefs, on the other hand, engender compensatory strategies, a key behavioral
component of the CBT conceptualization. Compensatory strategies are schema-
influenced reactions that seem adaptive but which maintain maladaptive beliefs.
They can also be thought of as self-defeating or self-handicapping behaviors,
although when viewed through a conceptualization of the operative belief system
(and their function in the environment in which they developed), they often
make sense.
Consider a client whose personal history is rife with abuse by a relative,
which has resulted in a mistrust schema and belief that “those who say they care
for you the most will hurt you the most.” In the abusive environment in which
this schema developed, it was an adaptive survival strategy. Years later,
however, it becomes maladaptive when in a healthy dating relationship, the
client overreacts to a trivial dating snafu by threatening a break-up. This
compensatory reaction makes sense on the basis of the clientʼs history and the
activated schema (and strong affect) of the core mistrust of others, especially in
intimate relationships. Failure and defectiveness/shame are the two most
common schemas endorsed in preliminary studies of adults with ADHD
(Miklósi, Máté, Somogyi, & Szabó, 2016; Philipsen et al., 2017). The failure
schema represents the belief that an individual has not achieved as much or
performed as well as peers or otherwise met expectations, which can leave the
individual feeling inept. The defectiveness/shame schema can be viewed as a
personalization of failure (i.e., the sense of being basically flawed as a person).
Avoidance and disengagement are the most common compensatory strategies in
adults with ADHD stemming from studies on negative thoughts (see Chapter 2,
this volume).
CBT is a here-and-now therapy because it emphasizes distress relief by
targeting immediately relevant life problems. It does not ignore the role of
personal histories, but emphasizes how their conceptualization informs treatment
to enhance a clientʼs current and future coping and well-being.
A focus on managing specific problematic events and situations tied to
therapy goals is central to CBT sessions, particularly for adults with ADHD.
Schemas and core beliefs (including those shaped by living with ADHD) set the
stage for a clientʼs reactions to and interpretations of the events in their day-to-
day life, in either adaptive or maladaptive ways. Consequently, it is the reviews
of such reactions that elicit negative automatic thoughts (Dobson et al., 2018).
Automatic thoughts are the quick interpretations of events interposed between an
event and a reaction. Most events in life elicit thoughts that are neutral and
fleeting, if not positive. Understanding that these automatic thoughts can be
distorted or otherwise unhelpful provides a means to consider other ways to
make sense of problematic situations, including those that require behavior
change to effectively manage (e.g., using coping strategies for ADHD).
Adaptively modified thoughts have effects on the chain of other thoughts,
emotions, behaviors, and physical reactions (and changes in any of these
domains reciprocally help modify thoughts). Figure 3.1 depicts a case
conceptualization diagram with modifications to highlight issues particularly
relevant for adults with ADHD.
FIGURE 3.1. Case Conceptualization Diagram Modified for Adult Attention-Deficit/Hyperactivity
Disorder (ADHD)
EF = executive function.

ADHD does not result from maladaptive cognitions, but life with ADHD and
experiences colored by its related frustrations and impairments can result in such
maladaptive thoughts and schemas (see Chapter 2, this volume). Many aspects
of the behavioral domain of CBT have been adapted to address the characteristic
executive function (EF) deficits seen in adults with ADHD. The cognitive
domain plays a crucial mediating role in fostering the implementation of these
essential behavioral coping strategies.
The role of cognitions in treating adult ADHD requires adapting the CBT
model, and more specifically, thinking differently about cognitions. The next
section focuses on the cognitive domain and reviews the updated cognitive
model of psychopathology. Points of convergence and divergence of this model
with issues most relevant to adults with ADHD are highlighted, which is
necessary for the consideration of an adapted model for adult ADHD.

THE GENERIC COGNITIVE MODEL AND ITS RELEVANCE FOR

ADULT ADHD

Although earlier accounts of the cognitive model did not claim that distorted
cognitions played a causal role in depression or other emotional conditions, it
was implied (see A. T. Beck, 1967/1972). While still emphasizing a central role
of information processing on clinical conditions, A. T. Beck and colleagues have
recently updated the GCM and how it continues to adapt to new insights about
various conditions, most notably but not limited to depression and anxiety (A. T.
Beck & Bredemeier, 2016; A. T. Beck & Haigh, 2014; Clark & Beck, 2010).
These fine tunings reflect the GCMʼs ongoing assimilation of and
accommodation to scientific findings and other complexities involved in
understanding and treating psychiatric disorders and other forms of human
distress and functioning. These developments include conditions that several
years ago would have seemed unsuited for treatment with CBT.
 The GCM evolved from an initial model for depression (A. T. Beck,
1967/1972) in which cognitions play a central role with downstream effects on
the emotional and behavioral aspects of depressive syndromes. This model was
expanded to account for the array of emotional disorders, which are
distinguished by distinctive cognitive themes (A. T. Beck, 1976), and to inform
interventions for depression and anxiety disorders (A. T. Beck & Bredemeier,
2016; A. T. Beck & Haigh, 2014; Clark & Beck, 2010).
At its core, the applied GCM asserts that psychopathology is set off and
maintained when schema-activated factors (e.g., maladaptive beliefs, selective
focus, maladaptive behavior) are triggered by stimuli and interact (A. T. Beck &
Haigh, 2014). Once triggered, the schemas sway subsequent information
processing; the analogy of colored lenses is often used to illustrate this effect.
Schema activation has cascading effects on subsequent cognitions, selective
(biased) attention/focus, behaviors, and emotions (see Figure 3.1). Triggers may
be internal or external. Moreover, these schema-activated factors may generalize
to other situations that are similar to the original triggering events.
A central concept in the GCM is that of schemas and how they influence the
assimilation of new information (i.e., learning). Maladaptive schemas run the
risk of being either too rigid and fixed or too permeable, both of which result in
a disorganized, volatile meaning-making system. In terms of schema
accommodation (i.e., the capacity of schemas to be modified), schemas that are
repeatedly activated tend to be less open to change. In fact, the prospect and
pressure of change triggers schema activation, at which time the schema
becomes energized and dominates information processing, bringing about
psychological distress, effectively “hijacking” functioning. Adaptively modified
schemas, on the other hand, can deactivate or override dysfunctional schemas.
Consider the analogy of the software on a computer that requires updating.
Activated maladaptive schemas are like the current programs running on a
computer that must be closed before updates can be installed. Helping clients
reprocess emotional experiences (e.g., close open programs) and modify
schemas (or at least notice, accept, and work around them) is an essential part of
the change process (e.g., updates). In the case of adult ADHD, managing
emotional dyscontrol and escape–avoidance is essential for coping with EF
deficits and targeting schema activation that may interfere with these steps.
Several elements of the updated GCM are relevant to adult ADHD and
pertain to the role of cognitions: information processing biases, different types of
information processing, and the role of attentional focus and goal-oriented
behavior.

Information Processing Biases

The updated GCM (A. T. Beck & Haigh, 2014) continues to treat differences
between adaptive and maladaptive states as linked to information processing
with little concern about direction (e.g., whether depression causes distorted
thoughts or vice versa). Emotional disorders are accompanied by cognitive
biases, either negative (perceived misfortune or loss in depression) or positive
(potential reward from expansive action in mania), falling on a continuum from
adaptive to maladaptive. The capacity to feel sadness is adaptive with survival
benefits in certain settings (e.g., a grief reaction), but when taken to an extreme
(e.g., hopelessness, suicide risk), it is tantamount to an impairing mood disorder
(A. T. Beck & Bredemeier, 2016). These distinctive biases reflect the cognitive
specificity of disorders, the predominant themes of thoughts that differentiate
disorders form one another.
At an information processing level, a case could be made that adults with
ADHD accurately perceive difficulties and setbacks from their EF deficits and
other symptoms. The chronic delay in EFs to some degree creates a different
baseline of functioning. Clients with ADHD are comparatively late in their
development of EFs and self-control. This consistent inconsistency establishes a
baseline of functioning that makes ADHD a vexing condition. Many adults with
ADHD have self-judgments about what they “should” be doing (e.g., life choices
or day-to-day coping based on comparisons with adults without ADHD or
societal standards). These are commonsense benchmarks, but adults with ADHD
see them as markers of failure if they are poor fits, and they can create letdowns.
The notion that there is a degree of accurate perception of difficulties inherent
in managing ADHD should not be read as implying that the information
processing assumption is not relevant. Rather, in the case of adult ADHD there
are maladaptive negative thoughts that interfere with modifying and
implementing coping strategies, as well as maladaptive positive thoughts that
promote avoidance or poor decision making (underlying apparent risky choices;
Dekkers et al., 2018). Managing ADHD requires an adjustment of a clientʼs
mind-set as managing EF deficits require different coping skills and different
ways of using them. In fact, because it is a neurodevelopmental syndrome
cutting across most life domains and roles, the information processing
difficulties for adults with ADHD may be more wide-ranging when compared
with other conditions.

Types of Information Processing

Within the GCM, a distinction is made between automatic and reflective
information processing. The former represents in-the-moment reactions to events
that require quick categorization, a response that is prone to distortion; the latter
style is more deliberative and more taxing in terms of its cognitive load when
sorting out the nuanced factors relevant to an event. This distinction is consistent
with the dual processes of a reactive, reflexive, and nonconscious rapid response
and a separate, deliberative, and effortful metacognitive analysis and synthesis of
events—the respective fast and slow thinking modes (Kahneman, 2011).
In terms of adult ADHD, this distinction parallels but overlaps with the
bifurcation of the EFs into hot and cool groupings (Barkley, 2012; Peterson &
Welsh, 2014; Tsermentseli & Poland, 2016). Hot EFs refer to the skills to
manage events that need an immediate response, which draw on capacities for
impulse control, emotion regulation, and motivation to quickly initiate or inhibit
a course of action. Cool EFs, on the other hand, refer to planning, time
management, and other metacognitive skills with which to handle problems and
coordinate goal-directed actions over time.
The fast–slow information processing domains in the GCM overlap with the
hot–cool EFs for adults with ADHD. EF deficits create the downstream life
impairments, which are the events and targets for psychosocial treatment. When
information processing is affected by cognitive distortions, these negative
thoughts (and corresponding emotions) often worsen EF deficits or at least
interfere with coping efforts, including therapeutic strategies. Thus, these
overlapping deficits may trigger and be triggered by one another.
The interaction of information processing and EF difficulties plays a
significant role in the maintenance of impairments and their moderation. For
example, adults with ADHD have problems inhibiting worrisome thoughts and
refocusing on more adaptive thoughts (Abramovitch & Schweiger, 2009); they
have trouble handling “hot” intrusive thoughts and using the “cool” system to
modify them. These represent distinct challenges within CBT for adult ADHD.

Attentional Focus and Goal-Oriented Behavior

The view of the stimulus–response network in the GCM goes beyond a linear,
stimulus–behavioral response mode, advocating a coinciding, proactive view
where goals, drives, and other conceptual motivations themselves are stimuli that
arouse, inspire, and initiate actions. This is similar to the discussion in Chapter 1
of this volume about the difference between a strict behavioral view of language
and cognition and the cognitivist view that extends the behavioral foundation
and asserts that thoughts, beliefs, and concepts represent aspirations and goals
that are influential and are targets for cognitive modification.
Attentional focus is a central issue in this process, as selective attention to
stimuli (e.g., conceptual goals) is an activating event, which can trigger either
adaptive or maladaptive beliefs and behaviors (A. T. Beck & Haigh, 2014).
When disordered, such as in anxiety disorders, there is an involuntary focus on
signs of sympathetic nervous system arousal (e.g., panic disorder) or uncertainty
(e.g., generalized anxiety). Such hyperactivated states of otherwise adaptive
systems trigger and are triggered by schemas and related beliefs tied to anxiety
themes of vulnerability and risk.
The very notion of difficulties directing and sustaining attention and efforts
toward goal-attainment gets at the heart of the matter in adult ADHD. By
definition, EF deficits, including nonverbal and verbal working memory deficits
(Barkley, 1997) and their role in thoughts and beliefs, punctuate goal-oriented
endeavors selected by individuals (Barkley, 2012)—they have “skin in the
game.” Attentional focus plays a somewhat different, arguably more prominent
and impairing role in adult ADHD than outlined in the GCM. A core problem
area in adult ADHD is erratic attention, distractibility, and/or poor sustained
focus, which undermine engagement and follow-through.
This leads to an important consideration for the CBT model for ADHD. The
GCM describes disorder-specific vulnerabilities for specific kinds of triggers
that bias attention. For example, panic disorder is associated with selectively
attending to bodily symptoms, which are tied to activated schemas of
vulnerability (A. T. Beck & Haigh, 2014). For adult ADHD, on the other hand, it
is the symptomatic proneness to distraction that commandeers attention from
priority tasks. These tasks are themselves triggers for maladaptive schemas (e.g.,
failure schema) related to the ability to perform them in the first place, which
further influences selective attention and focus (see Figure 3.1). These respective
external and internal vulnerabilities (e.g., triggers) are tied directly to the core EF
deficits that further complicate and are complicated by in-the-moment
information processing biases (maladaptive thinking) in real-life situations.
There is not the same singular thematic coherence between attention bias and
goal-oriented behavior in ADHD that exists in other disorders, as attention
problems in ADHD cut across all settings and roles. This situation may have
heretofore defied attempts to specify a cognitive theme.

Summary of the Generic Cognitive Model and Adult ADHD

The overarching GCM has relevance for adults with ADHD and CBT as a
psychosocial treatment, though there are features of the GCM (e.g., attentional
biases) that are especially and differently relevant for adults with ADHD, as
these are dispositional features of ADHD itself. Even when distilling the GCM
down to its use in treatment to target specific situations, the common factors of
an event, belief, and behavior are now joined by the issue of attentional focus
(see A. T. Beck & Haigh, 2014), which is already a central, defining issue
affecting the experience of adults with ADHD.
There also are aspects of information processing for adults with ADHD that
require some adjustment from the GCM to adequately address in clinical
settings, including an assumed baseline of functioning. For most episodic
disorders, progress, and ultimately remission, is determined by a return to
premorbid functioning, whatever that might be. A frustration faced by adults
with ADHD is that they are striving to return to a baseline that has never actually
been established, at least in a stable, dependable manner. In fact, some clients
note that their symptoms had increasingly marked effects on functioning as they
grew up and faced greater demands and expectations for intact self-regulation at
different points in life—the targets at which individuals with ADHD were
aiming kept changing.
The goal of a return to baseline functioning reflects a rehabilitation model of
treatment designed to restore a previous level of functioning. Habilitation
models, instead, aim to adapt to and optimize a clientʼs style of functioning,
which includes customizing and routinizing coping strategies tailored to their
needs, such as those for ADHD. At its best, CBT for adult ADHD operates as an
abilitation approach. It helps individuals establish newfound levels of consistent
functioning through effective coping (often with medications) from which to
nurture aptitudes and talents that may be tramped down by ADHD (Ramsay &
Rostain, 2015b).
A parallel to the situation for adult ADHD is seen in Grant, Huh, Perivoliotis,
Stolar, and Beckʼs (2012) recovery-oriented model of cognitive therapy for
schizophrenia. Defeatist beliefs have been established as the cognitive theme in
schizophrenia and treated through a person-oriented (rather than symptom-
oriented) approach, promoting functional improvements by targeting clientsʼ
interests and strengths. There is no causal role ascribed to these beliefs in
schizophrenia, but adapted CBT has produced gains in social functioning,
independence, and productivity (Grant et al., 2012).
A hallmark of the GCM and CBT over the decades is this sort of cognitive
specificity, the distinctive cognitive fingerprints that differentiate psychological
disorders. For ADHD, there is not this same direct and distinct line between
cognitive themes and specific symptoms. ADHD is not an emotional disorder
that yields a predominant emotional theme or valence. Moreover, there is not a
central domain of experience that defines ADHD in the same way as it is defined
in other disorders that are not fundamentally emotional (e.g., distorted
assessment of body image in body dysmorphic disorder, addictive beliefs in
addictions). ADHD is all over the place in its effects on experience and
functioning. The next section introduces a proposed cognitive theme that
distinguishes adult ADHD. This sets the stage for a review of the CBT model
adapted for adult ADHD.

PRIMARY COGNITIVE THEME OF ADULT ADHD

A unique element of the CBT model of psychopathology and the GCM is that
different psychological disorders are distinguished by distinct, specific cognitive
themes. The study of cognitive distortions in understanding and treating ADHD
has yielded the innovative ADHD Cognitions Scale for Adults (Knouse,
Mitchell, Kimbrel, & Anastopoulos, 2019). This scale is composed of
maladaptive positive thoughts and is highly associated with impairment,
avoidant coping style, and time management difficulties. The function of the
items making up this scale is as permission-giving thoughts that justify task
avoidance, though this is detrimental. In fact, Avoidant Thoughts Questionnaire
was considered as a name for the scale (L. Knouse, personal communication,
October 21, 2018).
This view is consistent with a study in which perfectionism was the most
frequently endorsed cognitive distortion (Strohmeier, Rosenfield, DiTomasso, &
Ramsay, 2016). The function of perfectionism was viewed (on the basis of
clinically informed conjecture) as the need to have circumstances be just right to
engage in a task; anything short of that standard would justify escape–avoidance
(Ramsay, 2017b), which is a common theme across studies of adult ADHD.
Nevertheless, the question remains: Is there a distinct cognitive theme driving
this maladaptive escape–avoidance? The previous examples reflect endpoint
justifications or permission-giving beliefs that allow for maladaptive escape–
avoidance coping and related impairments for adults with ADHD. These
impairments and recurring self-regulatory difficulties characteristic of ADHD
create conditions ripe for the development of maladaptive thoughts and failure
and defectiveness/shame schemas documented in preliminary studies. It is
similar to excessive speeding while driving, which is a unique symptom of
ADHD (Barkley, Murphy, & Fischer, 2008). A poor driving record is an
outcome (the impairment), and the excessive speeding is the underlying
symptom that leads to the outcome. Permission-giving thoughts justify escape–
avoidance coping, which is the symptom, and the functional impairment is the
outcome.
However, what activates the launch sequence of permission-giving thoughts
that result in maladaptive escape–avoidance and the downstream impairments
typical of this population? ADHD is a self-regulation problem related to poor
organization of behavior over time. Is there a mediational cognitive theme that
develops from this core deficit that makes adults with ADHD more prone to
dysfunctional avoidance and subsequent impairments that can be isolated and
inform psychosocial treatment, at least at the cognitive level?

Personal Agency and Self-Efficacy

Escape–avoidance cognitions in cases of adults with ADHD can be seen as
signifying a sense of impaired personal agency, which is the power an individual
has to influence or make things happen by intention in their life. Agency is the
broad sense that an individual can improve their circumstances by taking actions
to achieve a particular outcome (e.g., seeking education or training in a topic or
skill). Perhaps impaired agency is the main theme in adult ADHD.
However, there are settings and conditions in which adults with ADHD
exhibit intact personal agency. Even when facing difficulties, adults with ADHD
express frustration with an awareness that tasks are within their capability to
perform, that they are not fulfilling their potential, though they have difficulties
with consistent performance in various roles. Even in cases of problems because
of poor decision making or avoidance in which clients may have set themselves
up to fail, there is a sense that “I can do better.”
The issue may occur at the level of self-efficacy, the propositional belief in an
individualʼs ability to organize and execute specific courses of action designed
to achieve given outcomes (Bandura, 1997). Self-efficacy takes a satellite view
of a map of potential agency and directs it toward a specific destination relevant
to an individualʼs life. Based on the understanding of ADHD as a self-regulatory
deficit, adults with ADHD would seem to doubt their ability to follow through
on such goal-directed plans, which would make impaired self-efficacy a possible
cognitive theme.
Difficulties turning agency into self-efficacy mirror the notion of ADHD
being a problem of implementation or being unable to turn intentions into
actions. For example, this can manifest as a clientʼs belief in the ability to enroll
in and complete a specific degree or job certification program to improve
employability in the here and now. ADHD most certainly affects self-efficacy at
this level, but adults with ADHD typically select reasonable goals for themselves
for which they otherwise have the capacity to complete despite having
difficulties consistently doing so. Some adults with ADHD make poor choices
(e.g., idealistic or impractical expectations or plans) that may consequently
undermine intentions. These choices may have resulted from avoidance of better
discernment and planning; however, there are also adults with ADHD whose
goals and expectations are simply unrealistic or naive, which is a different
clinical matter.
An impaired self-efficacy view of the cognitive theme of ADHD, however,
seems no different from arguments that could be made for the effects on efficacy
of depression, anxiety, and other conditions. A case could be made that each
disorder arrives at low self-efficacy differently and that ADHD arrives at it more
directly based on its core self-dysregulation, not to mention that ADHD is a
neurodevelopmental delay.
In fact, it seems that the main relevance of this agency/efficacy view for
ADHD and its difference from other disorders is better encapsulated by a
specific, lesser known facet of self-efficacy. It is at a more fundamental
implementation level at which functioning is affected, which sets ADHD apart
from other disorders.

Self-Regulatory Efficacy
An overlooked component of self-efficacy is self-regulatory efficacy, which is
the belief in an individualʼs ability to organize and carry out the basic steps
necessary to effect change (Bandura, 1997). This factor represents the ability to
organize, implement, and sustain the essential day-by-day, step-by-step chain of
behaviors (and mind-sets) necessary to complete a course of action that will
achieve the desired effects. Self-regulatory efficacy is virtually a rewording of
the EF deficit model of ADHD, though arrived at independently with no
previous mention of ADHD.
Bandura (1997) described self-regulatory efficacy as the capacity “to plan
and structure activities, to enlist needed resources; to regulate oneʼs motivation
through proximal challenges and self-incentives; and to manage the emotionally
and cognitively disruptive effects of obstacles, setbacks, and stressors” (p. 53).
These essential building blocks of self-efficacy are the very ones affected by the
EF deficits that define ADHD—poor motivation, delay aversion, distractibility,
and other self-regulatory deficits. Bandura also noted that
the activities of everyday life are strewn with frustrating, boring, stressful,
and other aversive elements. This is part and parcel of daily living. In
many spheres of functioning, people know full well how to perform the
needed behavior. Here, the relevant efficacy beliefs concern self-
regulatory capacities—can people get themselves to stick with the
behavior given the many dissuading conditions they will encounter? . . .
Those who distrust their capacities to surmount unpleasant factors have
little reason to put themselves through misery. In familiar activities that
must be performed regularly to achieve desired results, it is perceived self-
regulatory efficacy, rather than perceived efficacy for the activity per se,
that is most relevant. (emphasis added; pp. 63–64)
These passages do not mention ADHD, though they vividly portray the
quintessential challenges faced by adults with ADHD. The construct of self-
regulatory efficacy is a relative footnote in the efficacy literature. Mood and
anxiety problems are associated with avoidant behaviors, too, but in such cases
the basic, baseline self-regulatory skills are assumed to be intact, operative, and
available for recruitment in the pursuit of an objective, sapped only by the
effects of mood or anxiety symptoms. With ADHD though, persistent impaired
self-regulatory efficacy subverts functioning through repeated self-doubts based
on chronic implementation problems and consistent inconsistencies inherent to
the condition.
It is at the level of self-regulatory efficacy that adults with ADHD experience
problems that undermine their goals and create impairments; it is a street-level
view of the path to the desired destination rather than a satellite view. Trouble
navigating the distractions, dissuasions, and disruptions of requisite acts (e.g.,
waking up on time, paying attention to lectures and course materials, completing
assignments on time) is what undermines efficacy, agency, and the intentions
and goals of adults with ADHD. Furthermore, these core problems and cascade
of downstream impairments erode the confidence and self-esteem of adults with
ADHD, which lead to a greater proneness to justifications and permission-giving
beliefs for escape-avoidant coping. On the basis of preliminary research, this
often culminates in failure and defectiveness/shame schemas.

The Impaired Self-Regulatory Efficacy Theme

The primary theme in the thoughts and beliefs of adults with ADHD proposed
here is that of impaired self-regulatory efficacy using Banduraʼs (1997)
definition. This theme reflects the information processing biases inherent to
adults with ADHD when facing tasks, endeavors, and coping strategies
necessary in the pursuit of desired and feasible actions, plans, and goals. This
theme develops from recurring, punctuated efforts to organize and follow
through on endeavors because of ADHD. The downstream maladaptive
cognitions become increasingly entwined with the core features of ADHD and
result in permission-giving thoughts that magnify an existing susceptibility to
escape-avoidance coping, disengagement, and other barriers to the effective
management of ADHD.
Drawing on this overarching theme, at the level of specific cognitions and
beliefs, self-distrust is proposed as the primary theme in automatic thoughts and
a target for cognitive interventions in CBT for adults with ADHD. A frustration
voiced by clients with ADHD is their seemingly indiscriminate follow-through
on endeavors, sometimes doing so relatively well, but other times facing
significant difficulties. It is these ever-present doubts about a clientʼs ability to
effortfully carry out and stick with the everyday, necessary steps that not only
reflects the coping difficulties of ADHD, but also undermines attempts to use
coping skills.
ADHD, and more specifically the self-distrust ADHD engenders, factors into
automatic cost–benefit calculations of behavioral investments and associated
cognitive justifications for escape–avoidance (Henriques, 2011). Even adults
with ADHD professing adequate self-efficacy in advance of an endeavor waver
as the time for action draws near when performance doubts become more salient
and result in avoidance (Bandura, 1997), such as the complaint voiced by adults
with ADHD that they are good at making realistic plans but not following
through on them. These justifications stem from a reflexive impulse (e.g., “I
know Iʼm capable of this task but Iʼm not sure I can do this right now”), which
reflects the self-distrust cost of ADHD embedded in most tasks and endeavors.
The recurring behavioral inconsistency and its effects on life functioning lead
to the failure schema, the most common schema seen in adult ADHD (Miklósi et
al., 2016; Philipsen et al., 2017). When adults with ADHD face an overarching
pattern of avoidance, it creates the self-mistrust schema (Ramsay & Rostain,
2005a, 2015b). It is this visceral self-mistrust that interferes with engagement
and sets the stage for failure experiences and ensuing failure beliefs (e.g., “I
cannot count on myself to do what I need to do”), which can also lead to feelings
of shame. The terms distrust and mistrust are often seen as equivalent. However,
a nuanced difference is that the former is based on experience and specific
concerns and the latter reflects a general unease, suitably differentiating the
respective automatic thought and schema levels of information processing.
The classic mistrust schema (J. E. Young, 1999) refers to other-directed
mistrust, such as the example of the survivor of abuse discussed earlier in this
chapter. In that example, the other-directed mistrust schema was activated in
response to a trivial snafu made by the clientʼs partner, which activated an
extreme response in the client because of suspicion about the partnerʼs
trustworthiness. For adults with ADHD, the self-mistrust schema takes the form
of self-directed misgivings about their general dependability; they feel they
cannot rely on themselves to follow through and perform tasks as expected or
desired. Self-mistrust reflects the adverse effects of ADHD on self-regulatory
efficacy and thus an individualʼs schema, which may lead to a failure and/or
related schema.
An immediate objection to this proposal is that self-efficacy is negatively
affected by all conditions (e.g., a person with depression doubting his or her
ability to complete tasks at work). However, it is the symptoms of depression
that interrupt and suspend premorbid, baseline levels of efficacy but not
necessarily the levels of self-regulatory efficacy, at which ADHD operates and is
defined. These concepts help crystalize the cognitive elements of clientsʼ
accounts of recurring and impairing problems.

Clinical Relevance
So, how does the proposal that the main cognitive theme in adult ADHD is
impaired self-regulatory efficacy, self-distrust thoughts, and self-mistrust beliefs
help therapists treat adults with ADHD? These are clinically derived conjectures
and hypotheses to be tested. There are measures of self-regulatory efficacy
designed for and used in isolated studies but none to date have been used with
adults with ADHD. However, it is a starting point that is theoretically coherent
and a clinically useful heuristic for therapists that informs implementation-
focused CBT for adult ADHD, as is illustrated in the following chapters.
The first point regarding the clinical relevance of the cognitive theme is one
made at the outset of the book that cognitions about endeavors play a necessary
role as a ligament between intention and action, between plan and performance
for adults with ADHD. The cognitive domain helps to foster better behavioral
engagement, emotional engagement and acceptance of discomfort, and
interpersonal self-advocacy, among other manners of reducing escape–avoidance
coping. A case can be made that some adults with ADHD struggle with the
effects of maladaptive engagement (e.g., errors of commission from impulsivity,
emotional overreactions). Therefore, a corollary to the focus on such
engagement problems is to foster adaptive disengagement, which includes
cognitive interventions for managing impulsivity and emotionality that may be
viewed as beyond a clientʼs control (see Chapters 4 and 5, this volume).
Second, an important element in modifying impaired self-regulatory efficacy
is turning managing ADHD into navigating discrete pivot points, which promote
self-regulatory efficacy. Pivot points can be viewed as an intervention designed
to capture those windows of time and experience in which a client is on the
precipice of doing an action or not doing an action, engaging with it or
disengaging with it. At these points (and those leading up to them), cognitive
interventions are at their most influential in terms of clients engaging in the
desired actions and fulfilling their intentions. This implementation-focused
approach to CBT is designed to help adults with ADHD define and more
effectively navigate these small, achievable joints in daily affairs, where they
can use tactics with which to implement strategies and plans (see Introduction,
this volume). It is at these junctures that abstract plans and goals are turned into
tangible actions and experiences. This is where the cognitive domain of CBT is
most immediately relevant for this behavioral outcome in the form of framing
and defining tasks in ways that promote implementation, which is then enhanced
by the felt experience of getting things done, thereby reinforcing adaptive
thoughts and beliefs. Cognitive approaches are interwoven with behavioral
strategies and tactics, and externalized prompts and incentives to promote
engagement (owing to reward deficiency and delay aversion).
From this foundation of engagement, another notion for the cognitive domain
of CBT comes into focus—ADHD as a self-definition issue. Inveterate life
frustrations can result in toxic conclusions about a clientʼs worth, abilities,
usefulness, and value. A quick online analysis of the definition of efficacy
yielded synonyms like usefulness, worth, value, capability, virtue, and
effectiveness, and antonyms like inadequacy, incompetence, ineffectiveness, and
failure. These terms serve as a telling reminder that the distrust/mistrust themes
seen in clinic-referred adults with ADHD are not merely pesky, short-lived
reactions but predominant cognitive themes. Beyond proximate frustrations with
tasks, ADHD relentlessly punctuates and disrupts personally valued pursuits and
goals, which can be corrosive to and erode an individualʼs sense of self.
As was noted previously, additional adaptations to a CBT model for adult
ADHD are required, including accounting for the influence of thoughts and
beliefs and emotions relevant to this clinical group. The next section outlines a
CBT model for understanding and treatment of adults with ADHD.

COGNITIVE BEHAVIOR THERAPY MODEL FOR ADULT ADHD

This chapter reviewed the CBT case conceptualization and corresponding GCM
that provide the framework for the overarching CBT model of psychopathology
and the cognitive, information-processing aspect of CBT, respectively. The
adaptations of these approaches that make them relevant to adults with ADHD
were outlined, including impaired self-regulatory efficacy as the proposed
central cognitive theme in the thoughts and beliefs of adults with ADHD. The
next sections summarize the guiding conceptual premises about ADHD that
inform the clinical premises that guide psychosocial treatment, namely the CBT
model for adult ADHD that guides the interventions discussed in subsequent
chapters of this book.

Conceptual Premises About ADHD

This section presents a series of premises about ADHD and its effects that
inform the premises of a CBT treatment model for adult ADHD. There are
several CBT manuals that provide theoretical models (Ramsay & Rostain,
2015b; Safren, Sprich, Perlman, & Otto, 2017b; Solanto, 2011; S. Young &
Bramham, 2012). This book highlights the mediational role of cognitions and
cognitive interventions in the implementation of the essential coping strategies
for managing adult ADHD. This approach will also illustrate the reach of these
coping strategies into the domains of impairment that are often therapeutic
targets, many of which have not been typically viewed as having a cognitive
component to them. Exhibit 3.1 provides a review of the conceptual premises of
the CBT model of adult ADHD.

EXHIBIT 3.1
Conceptual Premises of the Cognitive Behavior Therapy Model of Adult ADHD
1. Attention-deficit/hyperactivity disorder (ADHD) plays an influential role in developmental experiences.
2. ADHD makes a direct and causal contribution to functional difficulties, with a range of effects on functioning and
coexisting difficulties that magnify and are magnified by other life stressors.
3. ADHD influences the experience of and performance in various life roles and endeavors, disrupting otherwise
reasonable personal goals and endeavors, which undermine a sense of agency and efficacy.
4. ADHD and its functional difficulties influence the reciprocal interaction between affected individuals and their
worlds, relationships, and sense of belongingness.
5. ADHD affects information processing in the form of a clientʼs profile of attributions, meanings, thoughts, and
schemas/beliefs, which influence functioning and is a target of psychosocial treatment of adult ADHD.

This adapted CBT model is based on several premises about ADHD. The first
premise is that affected individuals experience ADHD symptoms along a
continuum of severity and that these symptoms are present, in some form,
beginning in childhood or adolescence. These features emerge during the normal
course of development and over time become more apparent to the individual
with ADHD and to stakeholders (parents, caregivers, teachers) as affecting
functioning. Thus, ADHD to some degree shapes an individualʼs developmental
experiences.
The second premise is that ADHD makes a direct and causal contribution to
functional difficulties, ranging from interference to impairment (even when not
diagnosed in childhood or adolescence). There is variation in the effects and
severity of symptoms across time and within and across domains, settings, and
activities. There are often secondary skill deficits as EF deficits interfere with the
development and use of compensatory skills, including in cases of symptom
reduction or remission in adulthood when residual coping difficulties may
persist. Coexisting emotional, learning, and/or medical issues as well as adverse
life events can further complicate functioning. ADHD creates difficulties that
directly create functional difficulties in various domains of life, and these can
magnify and be magnified by other life stressors.
The third premise is that ADHD symptoms influence an individualʼs
experience of and performance in various life roles and endeavors. ADHD
disrupts otherwise viable personal goals and endeavors because of difficulties
consistently and effectively implementing plans and coping strategies. The
downstream effects of these difficulties interfere with social standing, well-
being, sense of self, and efficacy. This can range from the foundational
obligations of life (e.g., health, academics, work, relationship roles) to personally
salient endeavors (hobbies or other undertakings that contribute to an
individualʼs self-definition). The difficulties faced by adults with ADHD,
separately and cumulatively, undermine their sense of agency, efficacy (and self-
regulatory efficacy), and identity in terms of the pursuit of feasible, desired
goals, objectives, and endeavors.
This leads to the fourth premise, which is that the features of ADHD and
resultant functional difficulties influence the reciprocal interactions between
affected individuals and the contexts, settings, and environments in which they
live and function, particularly relationships with others. Self-regulatory
difficulties affect social capital in social settings and how feedback from the
social world influences actions (or inactions) by the individual. These
interactions, settings, activities, and relationships can either magnify or attenuate
difficulties, coping, abilities, talents, and sense of belongingness.
Hence the fifth and final premise, the experience of living with ADHD and its
characteristic self-regulatory difficulties affect an individualʼs information
processing in the form of the personal cognitive profile of attributions,
meanings, thoughts, and schemas/beliefs. These cognitive factors influence how
individuals construct their personal stories and justifications, as well as
emotional and behavioral experiences. This cognitive–behavioral–emotional
system results from reciprocal feedback and experiences compiled over years of
living with ADHD. This system, in turn, affects how adults with ADHD manage
situations, roles, endeavors, and relationships, which can lead to psychosocial
treatment. The stress from the consequences of ADHD-related impairment (e.g.,
perceived and/or actual devaluation by others, failure experiences) further
impairs self-regulatory functioning in a reciprocal manner (B. Rosenfield,
personal communication, February 1, 2019). Although treatment targets
behavior changes and improved functioning, the cognitive domain plays a
distinct, mediational role at specific targets, viewed as high-yield pivot points.

Clinical Premises and Treatment Implications

Based on these understandings of ADHD, the first premise of the CBT model of
adult ADHD is that ADHD represents a quantitative difference in degree of
symptoms and not a qualitative difference of type of symptoms. Individuals with
a diagnosis of ADHD fall at the disordered end of a continuum of normative
self-regulation in terms of the number, severity, and impact of symptoms and
impairments. Exhibit 3.2 provides a review of the clinical premises of the CBT
model of adult ADHD.

EXHIBIT 3.2
Clinical Implications of the Cognitive Behavior Therapy Model of Adult ADHD
1. Attention-deficit/hyperactivity disorder (ADHD) is a quantitative difference in degree of symptoms and not a
qualitative difference in type of symptoms.
2. ADHD is an implementation problem that undermines the necessary skills and strategies needed to effectively
manage endeavors.
3. Implementation problems stem from chronic self-regulation deficits that characterize ADHD, particularly organizing
behavior across time.
4. Self-regulation deficits (and coexisting issues) create a penchant for disengagement and escape–avoidance reactions.
5. ADHD and related impairments affect different levels of personal experience, including

cognitive/justification—modifying impaired self-regulatory efficacy

behavioral/investment—fostering adaptive behavioral engagement
emotional/experiential—managing and accepting discomfort
implementation—transitioning from being off-task to being on-task
 relationships/social influence—defining and fulfilling roles

6. The therapeutic alliance provides a foundation of empathy for and understanding of the challenges of living with
ADHD and encouragement during the change process.

The second premise is that ADHD is primarily an implementation problem of

difficulties performing the necessary skills and strategies needed to effectively
manage a task, endeavor, role, or situation. It is not a lack of knowledge of what
needs to be done or an incapacity to perform the requisite actions.
The third premise is that these implementation problems stem from chronic,
underlying self-regulation deficits characterized by difficulties organizing,
initiating, and sustaining actions over time to achieve future-focused, deferred
objectives that are personally salient and valued by an individual. The self-
regulation deficits manifest as problems with

1. procrastination;
2. poor motivation for behavior (initiation and maintenance over time);
3. poor task endurance;
4. difficulties sustaining efforts across time and/or working toward a deferred
reward;
5. the tendency to discount deferred rewards, which are experienced as less
salient than proximal rewards;
6. corresponding difficulties with initiating and sustaining attention, time-task-
effort-energy management, disorganization, poor working memory, poor
problem management and decision-making skills, and emotional
dysregulation, all of which punctuate experience and efforts; and
7. difficulties executing known and effective coping strategies for managing
these and related problem areas.

The fourth premise of the CBT model of adult ADHD is that these difficulties
magnify and are magnified by coexisting psychiatric, learning, or other
disorders, as well as other issues which contribute to a penchant for
“disengagement” from or escape–avoidance of what are otherwise feasible and
personally salient tasks, endeavors, roles, duties, goals, or objectives. This
disengagement is the central behavioral problem that is targeted in psychosocial
treatment; it may stem from one, some, or all of the self-regulation difficulties
mentioned in the third premise.
The fifth premise is that these self-regulatory deficits and impairments affect
different levels of client experience, each of which are targets for psychosocial
interventions, including the following:

1. Cognitive/Justification: This reflects the cognitive domain of treatment,

including the modification of cognitive distortions, maladaptive schemas,
and other unhelpful explanations or justifications. Cognitive interventions
focus on increasing self-regulatory efficacy through improved use of coping
modification strategies, fostering task-promoting cognitions and framing,
cognitive defusion, and handling barriers and setbacks. The cognitive
domain aims to improve the clientʼs efficacy, agency, and sense of self. Self-
regulatory efficacy such as self-distrust thoughts and self-mistrust beliefs is a
primary theme of this domain.
2. Behavioral/Investment: This domain reflects the targeted behavioral
outcomes of meeting goals and objectives, meeting self-needs, and fulfilling
obligations to others. The therapeutic focus is the personalization of coping
strategies for managing ADHD to increase their use in real-world settings,
including the selection/prioritization of tasks and endeavors. Fostering
adaptive behavioral engagement (and adaptive disengagement) and effecting
follow-through is the main theme of this domain.
3. Emotional/Experiential: The emotional domain of treatment addresses the
flexible up- and downregulation of affect in the pursuit of behavioral goals,
managing emotional dyscontrol, and the personal valuation of and
manufacturing motivation for tasks. Emotions are relevant to starting,
switching between, and persisting on endeavors as well as coping with and
 accepting the frustrations encountered in day-to-day life that are more
distracting and disruptive for adults with ADHD. Accepting and managing
discomfort is the main theme in this domain.
4. Implementation: This domain targets the use of specific self-regulatory tactics
and strategies designed to promote self-regulatory efficacy through
engagement in and persistence on tasks, endeavors, and objectives over time,
especially those with deferred outcomes. The main theme of the
implementation domain is the transition from being off-task to being on-task
at a specific time and place (or other pivot point) and otherwise transforming
intentions into actions.
5. Relationships/Social Influence: This domain targets the effects of ADHD on
a clientʼs social capital and dealings with others, which has effects on
personal role fulfillment and balancing between meeting the needs of the self
and supporting the needs of others and obligations in various relationships
and group roles. Assertiveness in self-advocacy and defining and fulfilling
roles (including self-compassion) is the main theme in this domain.

The sixth and final premise of the CBT model of adult ADHD is that the
therapeutic alliance is a vital source of empathy and support in the psychosocial
treatment process. ADHD can have negative effects on a clientʼs sense of
belongingness and on relationships. Therefore, having a stable, supportive
therapeutic relationship with a therapist or other helping professional who
understands the challenges of living with ADHD and those inherent in the
change process provides an essential base.
Adults with ADHD will require extra time, attention, personalization,
support, and empathy to use these steps, which is why the therapeutic alliance is
so important. Their ability to gather the mettle to pursue CBT after coming to
terms with an initial diagnosis or after previous frustrated change efforts is
poignant and inspiring. The CBT model of adult ADHD aims to conceptualize
the full picture of each adult with ADHD, target the difficulties encountered in
their day-to-day lives, and provide an actionable framework to improve
functioning, overall well-being, and a strong sense of self.

CONCLUSION

The goal of this chapter was to present a CBT model of adult ADHD and how it
derives from the classic CBT model and GCM with modifications. Different
intervention domains and central targets for each domain were presented to
address the wide-ranging effects of ADHD. Chapter 4 emphasizes classic
cognitive interventions informed by this model and how they are adapted to help
adults with ADHD.

KEY CLINICAL POINTS

The CBT case conceptualization is a useful clinical framework that

represents a synopsis of the larger GCM. The conceptualization helps
therapists to synthesize clientsʼ developmental histories, how these
histories inform schemas and core beliefs relevant to presentation,
including compensatory strategies that represent self-defeating attempts
to work around schemas, and the downstream connection of thoughts,
emotions, and behaviors associated with specific events.
The updated GCM includes several recent elaborations relevant to
adult ADHD. These include information processing biases and the
understanding that most adults with ADHD have faced more than their
fair share of frustrations and setbacks. The hot and cool types of
information processing are akin to the hot and cool EF systems that are
a core issue for individuals with ADHD. Attentional focus is closely
aligned with goal-oriented behavior in the GCM, and these attention
processes are used in CBT for cognitive, emotional, and behavioral
modification, though these processes are extant problems for adults with
ADHD.
The conceptual premises on which the CBT model for adult ADHD
is based were outlined, as well as the clinical premises and their
implications for treatment. Impaired self-regulatory efficacy was
proposed as the core cognitive theme in ADHD, characterized by self-
distrust thoughts and self-mistrust schema.
4
Cognitive Interventions Adapted to
Adult ADHD

The goal of this chapter is to apply the adapted cognitive behavior therapy
(CBT) model to the standard cognitive interventions for adult attention-
deficit/hyperactivity disorder (ADHD). The underlying theories related to the
executive functions (EFs) and other factors that contribute to the functional
impairments experienced by adults with ADHD and the CBT model modified
for adult ADHD provide means for understanding these problems and creating a
blueprint for change. The challenge for clinicians is to use and adapt this
blueprint to clinic-referred adults with ADHD, with particular attention paid to
the role of cognitions in adult ADHD.
CBT and associated therapeutic strategies aim to help adults develop and use
coping skills with which to offset functional difficulties related to the core
features of ADHD. Most cognitive interventions for ADHD are designed to help
clients use strategies with which to engage in and follow through on various
plans and endeavors and work toward realizing improved functioning and well-
being. The interventions presented in this chapter will be used in specific
contexts in the remaining chapters of this book.
Gloria was diagnosed with ADHD in college. Her struggles with time
management, disorganization, and procrastination had led to dropped and failed
courses, a voluntary semester off to regroup, and eventually, a delayed
graduation date. More than a decade later, she is now facing similar problems
with her quarterly productivity report at work. She knows full well that it makes
sense to get started early and work on it in small chunks, but nevertheless it ends
up being a cyclical ordeal for her.
By chance, a Friday afternoon meeting was cancelled, which freed up a few
hours Gloria dutifully reserved to work on the report due the following
Wednesday. When it came time to work on the report, however, she found
herself less inspired. She could not pin down exactly where to start and whether
she had all the requisite data. Gloria got occupied with other undone tasks, such
as responding to emails and voicemails and other sundry clerical matters. She
reassured herself that she would dispose of these nuisance tasks and then buckle
down on the report. At some point, Gloria was “on a roll” and kept plowing
through the lesser tasks; she justified tackling them first to free up time at the
end of the day when she could begin to make headway on the report.
At the end of her day, Gloria felt accomplished and caught up, although a
little spent. She decided to devote the rest of the workday to her lesser tasks and
work on the report at home that evening. Once she was home, Gloria busied
herself with chores and other tasks around the house. She sat down to view “just
one episode” of a TV program before getting to work on the report, but that
turned into a couch-bound evening of binge-watching. However, she took solace
in the fact she had the whole weekend to finish the report. As she readied herself
for sleep, determined to start fresh in the morning, she recalled a time when she
finished such a report in only a few hours.
By late Tuesday night (and into Wednesday morning), Gloria was furiously
trying to throw together a semblance of a passable report. It was unfathomable to
her that she was facing this scenario yet again. She choked back tears of
frustration and panic and doubted her ability to hold a “real” job. Gloria was
certain this would be the time she was exposed as the impostor she knew herself
to be. At the same time, she wrestled with a plan to call out sick as an excuse to
buy more time as a last resort.
When reviewing this scenario in her CBT session, Gloria admitted that she
knew she was procrastinating at each step, but still did it. When reverse
engineering her various delays, she said that she approached the report with a
vague plan (e.g., “I blocked out the cancelled meeting time for the report but
figured Iʼd be able to wing it to at least get started”), she doubted her readiness
and capability (e.g., “I have to do these reports each quarter but Iʼm still not sure
if I do them the right way; it is even harder to focus when I donʼt have a deadline
pressure; I second-guess myself”), she grappled with subtle feelings of unease
(e.g., “I got kind of antsy and was like, ugh, meh, when it came time to get down
to work”), she gravitated to more readily achievable tasks (e.g., “I felt really
good and on it after clearing out my inbox and stuff, though they really could
have waited”), and then she had a heartening rationalization (e.g., “I figured Iʼd
get it done somehow; I work best under pressure”). After everything, Gloria was
late with the report and issued a formal write-up by her boss.
The benefit of the CBT model for adult ADHD is that it provides a
framework for specifying the pivot points involved in the disengagement from a
task. In the case of Gloria, it helps her understand exactly how she procrastinated
on the report rather than having her simply try harder next time. Gloriaʼs pivot
points are illustrated by the parenthetical descriptions of her well-meaning
intentions that were not actualized. In fact, the pivot point itself is a cognitive
intervention as it provides different outlook for thinking about a task. Rather
than Gloria working harder to not procrastinate, each of the junctures pinpoint
exactly when, how, and why she put off the report (e.g., a procrastination
“autopsy”). Change happens by implementing strategies at these points, but this
is the core difficulty for adults with ADHD.
The rest of this chapter focuses on established cognitive interventions and
how they are tailored for adult ADHD. Chapter 5 of this volume applies these
broad-based strategies to specific problem areas faced by adults with ADHD.
The outline of cognitive interventions and their applications provides a menu of
options from which strategies can be selected to match the needs of individual
clients. The next sections start with a broad-based view of cognitive change and
then home in on some specific strategies and cognitions relevant to adult ADHD.
IDENTIFYING THOUGHTS AND THEIR EFFECTS

Accurate self-monitoring (e.g., tracking behaviors) is a problem area for adults

with ADHD, so identifying a clientʼs thoughts is an important skill to develop.
For adults with ADHD, the question of “what am I thinking” or related check-in
is particularly useful for taking stock of a situation. It is a practical entry point
for judging a sequence of events and, in turn, offers a target for change. It is one
of the ways to make CBT “sticky” and portable for adults with ADHD and
serves an inhibitory function that introduces a pause and prolongation (in EF
terms) of events. This pause creates space for reflection on a chain of events and
the clientʼs reactions to them; it also allows for proflection or thinking forward
through options for interpreting events and acting on them.
With this pause, the next step is for clients to assess their interpretations of
events. This step involves catching the reflexive, automatic, “hot” cognition.
This detection is followed by a reflective, “cool” processing (with the pause and
reflection process itself serving as a “coolant”), which draws on the notion that
initial thoughts are often incomplete, distorted, or unhelpful. There are different,
more adaptive ways of construing (and managing) events. Follow-up questions
like “How is this thought affecting me?” “Is there another way to look at this
situation?” “What is my priority right now?” and “What are my options for
handling this situation?” help clients consider alternative outlooks and courses of
action. The process is best kept quick and simple for adults with ADHD, but
even producing one alternative doubles the clientʼs options.
One aspect of psychoeducation in CBT is the introduction of cognitive
distortions. These sorts of thinking errors are ubiquitous in human nature and are
often innocuous, fleeting, and nondisruptive (e.g., “Thereʼs never any parking
around here”). These distortions represent the hot cognitive system designed to
make quick judgments on the basis of limited information (e.g., thinking fast;
Kahneman, 2011), an adaptive but imperfect system that is prone to populate
gaps in information with best-guesses or conjectures.
There will be situations in which automatic thoughts are distorted and must
be reevaluated with a more deliberative system (e.g., “Thereʼs parking here, I
just have to park a few blocks away”; e.g., thinking slow; Kahneman, 2011).
Common distortions seen in adults with ADHD are reviewed later in the chapter.
Automatic thoughts about tasks and events may be misleading, and often more
useful views can be developed to foster engagement and follow-through (or
make the informed decision of adaptive disengagement).
At the outset of CBT, automatic thoughts are uncovered during reviews of
situations representative of overarching therapy goals, such as in Gloriaʼs
procrastination review. These after-the-fact reviews are an avenue for orienting
attention toward thinking patterns at these pivot points. This orientation helps
clients be mindful of cognitions as part of an overall functional analysis of
events. There are many instances when adults with ADHD note that their
thoughts are completely accurate, such as when Gloria noted that she misused
her time, missed the deadline, and was reprimanded as a consequence. It is
important to acknowledge these accounts and frustrations. However, these
accurate, reasonable interpretations can become the triggers or events for
subsequent thoughts and conclusions that may be assumed to be valid. In
Gloriaʼs case, she deduced that she was a “fraud and impostor” and that she
struggled with the report “yet again.” Although, her therapist noted this was
because Gloria fell into the same procrastination patterns as in past months. CBT
does not gloss over or minimize these difficulties but examines options for
facing them and learning from them, including handling difficult moments such
as when Gloria faced the consequences of the tardy report.
Some clients maintain that they do not have automatic thoughts. A
workaround for this claim is to review a situation and ask whether the client
might have had a positive thought. For example, Gloria mentioned that she did
not have negative thoughts about the report on Friday when she abandoned her
plan to start the report before leaving the office. The therapist asked if Gloria
might have been thinking, “Iʼm looking forward to getting started because late
Friday afternoon is a time Iʼm focused and motivated. Iʼm sure I have all the
data I need and if I donʼt, I know exactly how to easily obtain it?” Presenting an
opposite mind-set may uncover ambivalence about tasks. Inviting the client to
take steps during a CBT session, such as Gloria using her laptop to look up data
about her report, is another way to elicit hot cognitions and feelings.
Adults with ADHD often describe finding themselves in the grip of
distraction, like a college student automatically checking social media on his
arrival at the library, which runs the risk of undoing his study plan. Adapting
CBT to the self-dysregulation issues in ADHD helps to educate clients that
automatic thoughts do not necessarily appear first in a behavioral sequence or
even as complete ideas and reasoned decisions. In fact, there are times that
distractions or impulses truly occur without thinking.
Instead, a question like “What was it like being in your skin at that moment?”
helps to put words to these impulses, distractions, and other kneejerk
predispositions to identify them and their influence, even after the fact. In the
case of the distracted student, he concluded that his study plans were ruined, and
he left the library. His unspoken, prepotent impulse and rule—“I must check my
phone whenever I arrive somewhere”—was laid bare, and his therapist showed
how this context–behavior link innocently, yet insidiously, undid his intentions.
These sorts of cognitive–affective reactions may represent links to the delay
aversion (e.g., the preference for tasks providing more immediate reward)
common in ADHD. This penchant mixed with disinhibition and distraction may
create a visceral, unquestioned system of habits that are understood and justified
as “this is what I do.” Identifying and examining these cognitive–affective (or
affective–cognitive) patterns as unspoken rules is in line with this CBT
approach. Putting words on these impulses provides adults with ADHD with a
framework for understanding these patterns and, from this framework, they can
use targeted skills to change them at high-yield pivot points in the cognitive-
behavior (and emotion) sequence. This broadened use of cognition helps
uncover these pivot points to recognize and anticipate them, especially
seemingly “thought-less” ones.
Another useful way to put a finer point on the influence of automatic thoughts
is to determine whether a clientʼs inner self-talk has a tone of voice. When
Gloria described her barrier thoughts at the prospect of starting her report, she
said, “Iʼd have to go ALL THE WAY BACK to my computer, LOG ON, OPEN
the file, FIND the data, review it ALL, MAKE SENSE of it, and, by that point in
the day, it was like, UGH—Iʼm not in the mood for this,” with capitalized words
denoting those said in a manner implying great toil and effort. Her therapist
pointed out the tone of voice she used to describe these steps and, apart from her
words, that it likely reflected how she viewed and felt about the task. Gloria
acknowledged that, in retrospect, the actual steps were simple, but any aspect of
the report seemed onerous at the time. By reviewing the actual effort required for
tasks (e.g., “How long does it take to log on to my computer?”) and the effects
of the tone of voice/thought, Gloria was able to modify her outlook and uncover
and recognize task-related issues.
The role of cognitions for turning intentions into actions is an important
theme in this book, and how tasks are framed or packaged is an important
element to promote mind-sets that enhance follow-through. The terminology of
CBT includes distortions, dysfunctional thoughts, maladaptive schemas, and
other negatively tinged constructs that have precise meanings for clarity of
concepts and discussion. (Even ADHD includes deficit and disorder, and I
cannot think of another such “twofer” condition.) Some clients will latch on to
the existing jargon of distortions and find them useful, the names of which are
relatively innocuous (e.g., all-or-nothing thinking, mind reading); the
maladaptive schema categories (e.g., failure, defectiveness) can be more stinging
to others. The clinical task is to define with clients the vocabulary that
adequately captures the relevant cognitions and opens options for change.
The next step in CBT for adult ADHD is the modification of distorted or
otherwise unhelpful thoughts to foster more adaptive outlooks. The skill of being
able rework an initial interpretation has implications for emotions and behaviors.
The next section reviews various cognitive skills, starting with ADHD-friendly
ways for assessing and changing distorted thoughts.

COGNITIVE MODIFICATION: RETAINING YOUR DEFENSE

ATTORNEY

A classic cognitive intervention is the identification of an automatic thought

connected to an event or trigger (including other thoughts). The automatic
thought is then assessed to determine if it reflects a specific type of cognitive
distortion, how this interpretation was arrived at, and the evidence on which it is
based. The type, amount, and quality of evidence are judged, as is the utility of a
specific thought, even when facing seemingly incontrovertible evidence, such as
when Gloria mentioned being reprimanded by her boss for the late report (e.g.,
“If I donʼt improve, I will lose my job”). Other, more adaptive views of an event
and options for handling it are then considered. This practice of cognitive
modification cultivates outlooks and options that promote engagement in
personal endeavors and good functioning, which is an all-to-brief synopsis of a
complex process.
The Dysfunctional Thought Record (A. T. Beck, Rush, Shaw, & Emery,
1979), typically called a thought record, is a tool with which to externalize the
cognitive modification process. A thought record comprises successive columns
for recording a triggering event, automatic thoughts and distortions, emotional
reactions, and alternative thoughts. There are several variations of this format
(e.g., three columns for event, automatic thought, and alternative thought; two
columns for negative thought and alternative thought), and it can be modified to
whatever layout the client prefers.
Externalization of this process helps disentangle events, thoughts, and
feelings, which is very useful for adults with ADHD because of difficulties with
working memory. Many CBT-related apps offer digital permutations of this
basic framework. However, keeping track of and using a thought record,
accessing an app and entering and tracking information, or any other seemingly
trivial matters with their use are impediments for many adults with ADHD.
An adaptation of cognitive modification skills for adults with ADHD is the
coping card (from CBT for anxiety). Coping cards are index cards or any format
with which to store preformed, adaptive thoughts and other reminders for
handling certain situations. The cards serve to externalize and prompt skill use
rather than relying on free recall (akin to a multiple-choice test being easier than
a test relying solely on memory). In the case of anxiety, the coping card is used
to counteract the effect of mood-congruent memory, the proneness to gravitate
toward anxious thoughts and greater difficulty considering alternatives. Adults
with ADHD likely have task- or context-congruent proneness for aversion and
escape. Therefore, coping cards and other external coping reminders for
vulnerable situations can be helpful, such as those in which adults with ADHD
are prone for procrastination (e.g., “Define the first action step”), emotionality
(e.g., “Notice the feeling, donʼt act on it”), or impulsivity (e.g., “Let me think it
over”). Such prompts can be kept on physical cards or digitally. Visible
reminders of the steps for typical coping strategies, (Ramsay & Rostain, 2015a),
homework, or other useful information is helpful, if not essential for adults with
ADHD. Gloria developed a coping card to address her negative thoughts about
the write-up: “My boss is supportive. I have a plan for completing my work on
time.”
Organizing “stuff” such as coping cards and thought records is still tough to
do for many adults with ADHD. There is a need for handy coping tools that can
be used right away. One way to make coping strategies portable is using pithy
nicknames, analogies, cultural references, or practiced coping commandments
(Solanto, 2011) that resonate for clients in the hope that they will be used often
and become habitual.
To this end, a useful coping analogy for cognitive modification is that of the
defense attorney (Ramsay & Rostain, 2015a, 2015b). Automatic thoughts are
viewed as a case made by a prosecuting attorney (e.g., Gloriaʼs reactions to her
formal warning). The unquestioned acceptance of these thoughts is viewed as a
judge rendering a decision, not because the case (i.e., thought) or evidence is
necessarily strong, but because the prosecutorʼs case did not face any objections
or arguments made by a defense attorney on the clientʼs behalf.
The very exercise of considering what the defense attorney would say is an
inhibitory tactic that prolongs the moment. Framing automatic thoughts as
arguments made by attorneys obliges clients to reflect on them and to consider
whether they would stand up in court. The reframe is also consistent with
strategies of externalizing the problem and distancing or perspective taking (e.g.,
“If a friend of yours [with ADHD] was in this situation and had this thought,
what would you say to him or her?”). It may be, at least in part, that conjuring an
image of a person advocating for the client creates a sense that someone is on
their side. Regardless of the mechanism, anecdotal evidence suggests the defense
attorney question resonates with clients as a helpful coping tactic because it
sticks with clients and can be used outside therapy.
Cognitive modification often opens new ways to view and handle situations
to work toward a desired outcome. In some cases, though, there may be a
problem to be addressed despite achieving an adaptive mind-set. For Gloria, who
used the defense attorney analogy to good effect, viewing her write-up as “a
speeding ticket, not a felony” helped rein in her negative thoughts. She was able
to reread her bossʼs formal warning as providing clear steps for dealing with it.
She recognized her responsibility for changing her behaviors, half-jokingly
calling her boss her “probation officer,” which was used to view the required
action steps as “community service” that would enable her to expunge the write-
up.
The defense attorney analogy is a rebranding of cognitive modification or
restructuring. There are times when dealing directly with the content of
automatic thoughts is difficult, particularly during an emotionally charged
situation. Cognitive defusion strategies are useful during these and other
situations as yet another coping tool.

COGNITIVE DEFUSION

Whereas the defense attorney is a tactic for implementing cognitive modification

skills (e.g., reviewing the evidence for a thought), cognitive defusion can be seen
as settling out of court without a trial, with negative thoughts maintaining
visitation rights. Instead of examining the content of thoughts and their
messages, defusion strategies sidestep becoming embroiled with them in this
manner in the first place. Rather than contesting the veracity or usefulness of
automatic thoughts, defusion skills include refocusing on a priority endeavor or
simply staying in the moment despite the presence of intrusive thoughts, thereby
de-energizing them (Hayes, Strosahl, & Wilson, 1999). To illustrate the point,
therapists can ask clients to not think about a pink elephant. Attempts to comply
with the exercise result in noncompliance. Instead, with cognitive defusion, the
image of a pink elephant can bounce around in the clientʼs mind, but merely as a
nuisance that need not be evicted.
Defusion strategies ignore the content of a thought or what a client is
thinking, as efforts to dispute or suppress it only serve to maintain it (e.g., “I
must try harder to not think about a pink elephant”). Rather, thoughts are noticed
and regarded in a neutral manner to decrease emotional reactions while still
engaging in a planned action. Another analogy is to treat unwanted thoughts as
though they are seasonal allergies. Instead of being sidetracked by bothersome
sniffles, they are understood as symptoms of a harmless, though annoying,
allergy. The occasional sneeze can be tolerated without undue disruption.
Other coping images can be used to foster defusion, such as that of a leaf
floating on the wind, an incoming text to which does not need a response, or any
number of mindfulness-based, acceptance strategies. In fact, some forms of self-
talk, specifically referring to oneself by name, enhances such cognitive
distancing when responding to stressful situations (e.g., “Bob, this is a pink-
elephant thought—notice it and let it go”; Kross et al., 2014).
This discussion raises the question of whether clients should be changing or
accepting their thoughts. The answer is whichever works better for the client,
with most clients striking a balance between them. A more nuanced view is that
defusion strategies are helpful at the point of performance to tolerate discomfort
during a shift from disengagement to engagement or other times when the client
is in the midst of doing something (e.g., being willing to engage in a task when
the client does not necessarily want to do so; Hayes & Smith, 2005).
Modification strategies help with anticipations of task plans to make them seem
doable and stoke motivation and self-trust enough to approach them. Cognitive
modification also manages after-the-fact appraisals of quality and value of task
performance, such as discounting yes–but thoughts (e.g., “Yes, I studied, but I
should have started earlier”).
Cognitive defusion, mindfulness, and related process-oriented approaches to
cognitions, emotions, and behaviors reflect the ongoing evolution of CBT and
convergence of different but ultimately compatible ideas and therapeutic
approaches (see Hayes & Hofmann, 2018). These developments, considered the
third wave of behavior therapies (after the primary focus on observable
behaviors and the cognitive revolution; see Fishman, Rego, & Muller, 2011), are
useful for general clinical practice but are particularly relevant for a condition
such as ADHD, which potentially cuts across and through so many experiences
and life roles.
Often jumbled in with other cognitive interventions, reframing is a distinct
coping tactic. Framing and reframing play a vital role in managing ADHD,
particularly in defining and setting the stage for behavioral engagement.

COGNITIVE FRAMING AND REFRAMING

Reframing represents a shift in the clientʼs mind-set (e.g., how he or she makes
sense of a situation), which can be either positive or negative; the focus here is
on adaptive reframing. More specifically, the focus of this section is on framing
tasks, endeavors, and coping strategies to the degree that they are viewed as
feasible or doable. The framing is key because managing ADHD requires
modified coping approaches and workarounds to foster an adequate sense of
self-regulatory efficacy for engagement and follow-through, including
manufacturing motivation, breaking down tasks, and other steps discussed next.
Even the way information is presented makes a difference. In a classic study
(Tversky & Kahneman, 1981), physicians were asked to respond to one of two
differently framed vignettes about the administration of a treatment for a
hypothetical disease outbreak. The scenarios were presented as either risk-taking
(with the prospect of saving more lives) or risk-averse (with the prospect of
losing more lives), but both scenarios had equivalent survival probabilities. More
physicians endorsed the lives-saved vignette, although the risk–benefit was the
same.
A common frame encountered when working with adults with ADHD is that
of an individualʼs perceived capacity for an endeavor. Adults with ADHD often
voice examples of insufficiency (self-distrust) frames when facing tasks: They
are not in the right mind-set, they are not in the mood, they are too distracted, or
they do not have enough time or focus, all of which are quickly judged as
evidence of their inability to engage in a task (at least at that moment). This
verdict justifies avoidance of an undertaking that the person is otherwise capable
to perform and will be in the future, when things are right or enough—but not
now.
The enough reframe involves a shift from insufficiency to one of sufficiency,
having enough energy, ability, focus, or time for a task. The sufficiency reframe
counters the reflexive view that an individual is not up to a task at hand. This
reflexive view can be treated as a distortion, but framing provides an avenue for
empowerment by way of sufficiency or a sense of being ready or able enough. A
related coping tactic is the notion of lowering the bar or dissecting a larger task
into discrete portions until arriving at a point where clients believe they can do
the task: “Do you have enough focus to at least review your class notes for 10
minutes (or 600 seconds)?”
A compelling case has been made for the presence and effects of cognitions
coursing through the escape–avoidance behaviors common to adult ADHD.
Even in the myriad of examples of the effects of the core features of ADHD that
are the primary sources of disruption, there are often mind-sets that arise and
interfere with attempts to manage these disruptions and engage or reengage in
tasks. The next section reviews some of the more commonly encountered
cognitive distortions relevant to adult ADHD.

COGNITIVE MODIFICATION FOR COMMON DISTORTIONS

Preliminary research (see Chapter 2, this volume) has identified the relevance of
cognitive distortions in cases of ADHD, as well as those with coexisting
diagnoses. The following sections review the more common distortion patterns
and their relevance for adults with ADHD. These categories are standard fare for
any practicing clinician, but there are some nuances when approaching these
cognitions with adults with ADHD.

Perfectionism
Perfectionism has emerged as the most frequently endorsed distortion in a study
of adults with ADHD (Strohmeier, Rosenfield, DiTomasso, & Ramsay, 2016),
which was the first study to report on the frequency of specific types of
distortions endorsed by this group. Perfectionism is typically associated with
holding unrealistic performance standards and corresponding maladaptive
reactions when those standards are not met (e.g., when a minor blemish on a
project is viewed as nullifying the entire effort, the product, and/or the clientʼs
self-worth). These judgments can be based on an objective measure or ranking,
though a clientʼs subjective standards can be even more pernicious.
The fact that perfectionism is the most common distortion (Strohmeier et al.,
2016) was initially surprising until the result was reconciled with clinical
experience. A distinction can be made between front-end and back-end
perfectionism (Ramsay, 2017b), which goes beyond the study data but has
clinical utility. Back-end perfectionism can be viewed as having extremely high,
rigid standards for quality, details, and/or performance. This leads to difficulties
completing and submitting projects because they are not perfect enough or the
vague, nonspecific sense that they could be better. Assignments or projects are
late because of problems letting go of a desire to devote time and effort well
beyond that required to produce a high-quality product, though not necessarily a
flawless one.
Adults with ADHD, on the other hand, have difficulties organizing actions
over time, including completing tasks in a timely manner, usually because of
procrastination. Thus, front-end perfectionism reflects rigid standards or
preconditions that must be met for engaging in a task or endeavor in the first
place (e.g., “If circumstances are right, then I can perform the task”), but there
also exists a self-distrusting, conditional belief (e.g., “If circumstances are not
just right, then I cannot perform the task”). Adults with ADHD often describe
putting off tasks because conditions (internal or external) are somehow not
sufficient (e.g., “Iʼm not in the mood”; “The library is full”). In fact, there is
some truth in these concerns, as adults with ADHD are more prone to
distractibility and dissuading factors that others can better ignore.
Even though front-end perfectionism is more common (anecdotally) than
back-end perfectionism in adult ADHD, examples of back-end perfectionism are
seen. Some examples derive from a proclivity for hyperfocus (Hupfeld, Abagis,
& Shah, 2019), which in many cases is perseveration—the inability to stop a
current activity to switch and reengage in a different activity. Adults with
ADHD may get on a roll and spend inordinate time on a project beyond what is
required, often to the detriment of other duties and obligations.
This hyperfocus perfectionism is usually not about unrealistic standards;
instead, it is the feeling of being immersed in a task and the experience that, at
least for many adults with ADHD, “This is my best me, finally in the mood,
fulfilling my potential, and showing what I can really do.” This manifestation
could be considered as binge-efficacy (e.g., “Now that Iʼm finally started and
into this project, I want to make the most of this mode and not stop until I see it
through—I donʼt know when this might happen again”). This desire makes sense
given the frustration voiced by many adults with ADHD about not fulfilling their
potential.
Unfortunately, hyperfocus is often pressure-driven, such as facing a deadline
with a last-minute, marathon work session. At these times, the drive to start a
task is fueled by panic (e.g., “If I donʼt start right now and study all night, I
wonʼt be ready for the exam in the morning”). Some clients come to adopt such
brinksmanship approaches (Ramsay & Rostain, 2015b), often justified with the
thought that they work best at the last minute (Knouse, Mitchell, Kimbrel, &
Anastopoulos, 2019). This can be proudly held up as an identity trait, as it has
often helped adults with ADHD get out of jams in the past.
Hyperfocus in ADHD is not associated with risky behaviors, like those seen
in mania. Instead, it reflects an experience of being “in the zone” or a similarly
desired state. However, this state often interferes with a prudent and flexible
allocation of time, attention, and effort, and when it results in pulling an all-
nighter, it exacts a toll on sleep and well-being for days after. This sort of
massed practice or “cramming” is much less effective than distributed practice in
terms of preparation and output, particularly in academics (Dawson & Guare,
2009).
Another form of back-end perfectionism is the self-imposed ADHD penalty.
This penalty stems from the sense of guilt and shame often described by adults
with ADHD who assume they have disappointed others and are thus indebted to
them. For example, adults with ADHD often ask for help, request changes to
plans (e.g., deadline extensions), or accrue unrequited favors from others. When
coupled with poor follow-through on promises and not keeping up their end of a
relationship, adults with ADHD assume they are building up social debts they
cannot repay. These debts, real or imagined, diminish their assumed standing
with others, eroding their social capital. This view is often distorted because it is
based on an amalgam of situations and people selected to support a negative
view (e.g., sour cherry-picking), mind reading othersʼ views of them, and
discounting their own positive roles in these relationships.
The social impact of ADHD is often underestimated, and poor follow-through
does run the risk of creating discord with others. In terms of back-end
perfectionism and the ADHD penalty, presumed social debt puts pressure on
adults with ADHD to deliver a better-than-average result, which is often a
baseless assumption. Therefore, an already tedious task is made more daunting
by the self-imposed and inexact penalty, which raises the stakes for a promise
and fuels avoidance, a classic self-fulfilling prophecy.
For example, a college student with ADHD struggled to complete an essay
for which he had been granted a 2-week extension by his professor. During a
CBT session just before the essay was due, the client admitted he was stuck and
unable to wrap up the final details. When the therapist suggested lowering the
bar, noting the paper only had to be good enough to submit, the client responded
that his essay “has to be that much better because I had more time to work on it.”
In effect, this thought raised the bar on what was already a difficult task. The
client held a vague (and untrue) notion that he had to do more than classmates
but had no clue what this meant because it was conjured up by him.
In either type of perfectionism, cognitive modification aims to establish a
mind-set about circumstances or standards for a task that will promote
engagement. This might manifest as lowering the bar for the college student
described above who thought his paper would be held to a higher standard due to
his extension. This might also manifest as modifying assumptions about the
onboarding steps for an endeavor in the case of front-end perfectionism, like the
fact that an individual has enough time and energy to start a task and any initial
discomfort with it will likely be short-lived and bearable. These modified
outlooks address the extreme view in perfectionism that “everything must be
perfect or else I cannot do the task at all” that overlaps with the aim of finding a
healthy middle ground in all-or-nothing thinking, which is reviewed next.

All-or-Nothing Thinking
All-or-nothing thinking, also called black-or-white thinking, stems from an
affinity to catalogue, categorize, and evaluate experiences. This tendency is
maladaptive when it unfairly diminishes the options for managing a situation by
dismissing or overlooking vital factors. This usually results from ignoring the
complexity of events that do not fit neat categories but instead requiring gray
areas to accurately judge and manage them. For example, a client may judge his
or her performance in absolute terms (e.g., success or failure) rather than having
it fall along a continuum (e.g., “Iʼm getting better but I can still make
improvements”).
All-or-nothing thinking often arises when assessing progress in CBT.
Because of guardedness for perceived failure (often informed by past setbacks),
early signs of difficulty make adults with ADHD prone to conclude CBT is not
working and fall into escape–avoidance patterns. This reaction may reflect a
compensatory strategy, a preemptive strike against failure (e.g., “Iʼm not doing
better, CBT cannot help me. I will stop now before Iʼm told that I canʼt be
helped”).
The risk of premature dropout from CBT can be anticipated in early sessions.
The therapist can normalize invariable slip-ups as a therapeutic feature of CBT
for adult ADHD. It can be noted that the relapse rate for procrastination (or other
EF issues) is 100%—it is not whether it will happen but rebounding when it
does. The task is to face relapse and learn from setbacks, adjust, refine coping
skills, and get back on track and to improve by working through slip-ups
consistent with the notion of antifragility (Taleb, 2012).
 A role of therapists working with adults with ADHD is to highlight
incremental gains. For example, timeliness may be a CBT goal with arrival at
CBT sessions providing a target for skill practice. Over the first few meetings, a
client may improve from being 15 minutes to 20 minutes late to being under 5
minutes late. However, she may be frustrated that she is still late, and in an all-
or-nothing view, this is true. If she must swipe in with an ID card at work that
monitors arrival time, 2 minutes late is still late, which remains a therapeutic
issue for her job. In terms of behavior change, though, she has made notable
progress. Falling short of a goal may be seen as failure despite progress, a view
to which adults with ADHD are quite prone.
Ongoing effort is needed to manage ADHD. Therapists can point out
progress being made and give specific examples of behavior change as
movement along a continuum of change (e.g., “You are making progress, and
there is more we can do to build on what you are doing”).

Magnification/Minimization
Magnification/minimization is the tendency to disproportionately exaggerate
some aspects of an event and correspondingly minimize others, usually
magnifying the negative and minimizing the positive. This mode of thinking is
seen in cases of ADHD when a client faces some sort of mundane task that is not
inherently enjoyable (e.g., homework, a work project, or a tedious clerical task).
Difficulties and impediments related to the task are magnified (as these are
prepotent, immediately compelling concerns), and the likely benefits, such as
making progress on the task and the satisfaction of doing so are minimized (as
these are deferred gains).
Cognitive modification of this distortion involves a recalibration of the
magnification-to-minimization ratio. The very step of recognizing this distortion
serves to inhibit, or at least delay, an impetuous escape from a task. The
expected and magnified difficulties of a task at hand are assessed and
downgraded in terms of how bad or insurmountable they seem; conversely, the
deferred benefits of a task are upgraded in terms of their value and the clientʼs
ability to achieve them. This process is coupled with lowering the bar for the
task at hand, which helps upgrade the clientʼs self-regulatory efficacy for the
task. This process also serves as cognitive exposure of thinking through a task to
reduce emotional discomfort. There need not be a complete reversal of the
negative-to-positive ratio such that all discomforts are eradicated and the task is
viewed as all good; rather, this process serves to recruit enough “swing votes” to
make a task doable, consistent with modifying the quick calculations of the time,
effort, and energy costs of tasks that influence engagement versus
disengagement (Henriques, 2011).

Comparative Thinking
There is a typical degree of social comparison that shapes an individualʼs self-
definition. People iron out ways to use and enhance their talents and strengths in
life while working around and accepting their relative shortcomings, often
through observations of and interactions with others. Comparative thinking,
though, becomes maladaptive when people make patently unfair appraisals. This
is especially so for clinic-referred adults with ADHD for whom living with the
condition entails working harder, differently, and often less effectively than
peers in similar settings. In fact, there are times when the results of a clientʼs
efforts fall well short of expectations despite the time and energy expended.
(Copps, 2000, noted that adults with ADHD often “work twice as hard for half
as much.”)
Adults with ADHD are particularly prone to this distortion because they use
others and assumed societal standards as reference points for the “right” way to
manage affairs, such as work, school, and personal life, which are common
reference points for everyone. The typically effective coping methods that are
fine for most people, though, are often not as easily or well used by adults with
ADHD if not adapted to the nuances of the condition. Therefore, while an adult
with ADHD is agonizing over a common problem (e.g., lateness, forgetfulness,
misplaced keys), examples may come to mind of people who do not have such
struggles (e.g., “My sister the attorney is not on her hands and knees right now,
scrounging under the couch looking for her keys after she overslept”).
Comparative thinking may appear as everybody else/nobody else thoughts:
“Everybody else is on time despite busy schedules.” “Nobody else misplaces
their keys every day.” There is some truth to these reactions as adults with
ADHD have such problems with greater frequency and magnitude of effects. It
is noted, though, that effective coping is effortful for those without ADHD, as
they rely on many of the coping tools that are advised for managing ADHD. The
cognitive shift is to affirm and telescope in on a clientʼs specific issue and craft a
personalized, actionable plan: “I need a system for keeping track of my keys.”
Adults with ADHD often must use different tactics than their peers without
ADHD to implement the requisite coping strategies and tools. That these
strategies and tools are virtually compulsory for managing ADHD, yet clients
still struggle with their use often triggers a sense of shame and feeling different.
Shame is an emotion associated with the perception that an individual has acted
in a way that diminishes self-respect and social standing with others, including
feelings of humiliation (as opposed to guilt, an emotion associated with a
perceived mistake).
Recalling that the selection pressure for EFs in humans was social demands
of group living for reciprocity and cooperative efforts (Barkley, 2012), with
cognitions functioning as self and social justifications for an individualʼs actions
(Henriques, 2011), it makes sense that adults with ADHD are prone to such
reactions. Adults with ADHD often describe their struggles in terms of their
effects on relationships and social capital despite efforts to change (which may
involve mind reading, the distortion of presuming to know othersʼ reactions). In
fact, a unique benefit of group CBT for adult ADHD is that it provides a
community of individuals, including group leaders, who understand the struggles
associated with ADHD and affirm that the client is not the only one facing these
things (Groß et al., 2019; Solanto, 2011).
It was noted that ADHD is a quantitative difference and not a qualitative one
insofar as it is a delay in the development and maturity of normative self-
regulatory behaviors. This quantitative difference often makes clinic-referred
adults with ADHD believe and feel that they are qualitatively different. While
affirming the challenges posed by ADHD, the therapist can note that everyone
uses organizational and time management tools and that procrastination is
ubiquitous.
In a similar vein, many adults with ADHD describe an impostor syndrome,
that they are scrambling to get by under the radar before others figure out that
they do not belong, which was a concern voiced by Gloria. This theme underlies
many comparative thoughts. Some adults with ADHD will preemptively
withdraw from and avoid roles and obligations to circumvent failure, restricting
their activities and options, and otherwise shrinking their worlds and lives,
creating an invisible fence of ADHD (Ramsay, 2011b).
It is granted that managing ADHD requires customization of basic coping
strategies. Any of the strategies can be tailored to a clientʼs needs, like using
colored highlighting to differentiate types of tasks in a planner or taking a
reduced class load in college. A client who struggled to plan and put together a
shopping list in advance of grocery shopping devised a reverse shopping list; she
would go to the store, see what she was confident she could prepare, and
construct a menu in that fashion. She spent more time at the store, just as a
college studentʼs reduced course load requires an extended graduation date, but
these adjustments made her primary goal manageable and increased her self-
regulatory efficacy. The cognitive shift is finding what works for a client.
The distortions reviewed here are those commonly encountered in CBT for
adult ADHD. (The highlighted CBT manuals in the reference list include other
distortions relevant to adult ADHD.) The next section focuses on other ways to
modify thoughts.

OTHER COGNITIVE CHANGE TACTICS

There are a variety of strategies for modifying thoughts apart from those
mentioned. Socratic questioning is a classic intervention in CBT (A. T. Beck,
1976; J. S. Beck, 2011; Wenzel, 2019), the ideal of guided questioning and
conversations that aim to uncover and analyze a clientʼs thoughts and tacit rules.
The relative accuracy and utility of these cognitions are examined through this
inquiry as well as pondering exceptions, adjustments, and alternatives to these
initial reactions, which externalizes them and the process. The time between
sessions offers opportunities to try out different behaviors, catch and work
through a clientʼs thoughts in real settings, entertain different outlooks, and
otherwise take active steps that hold the promise of improved functioning.
Guided discovery requires much more structure, redirection, and outright
guidance by therapists to keep sessions on track and productive when working
with adults with ADHD. This does not suggest impersonal drill instruction or
inflexibility in session agendas. Rather, this guidance takes the form of
observing drift and ensuring actions of the session are in line with client
intentions. Nonetheless, the coping tools and strategies for adult ADHD are a
therapeutic touchstone, shaped by a grasp of the clientʼs goals, difficulties, and
case conceptualizations.
As disengagement and escape–avoidance are the predominant reactions
associated with ADHD, a central task of cognitive interventions is to foster
engagement with various coping strategies. Some of the useful cognitive
strategies adapted for adult ADHD are reviewed next.

Therapeutic Homework: Fostering Engagement in Field Experiments

The use of coping strategies in specific life roles and endeavors outside of
therapy and corresponding functional improvements is the essential measure of
therapeutic change. Therapeutic homework supports these outcomes through the
recruitment of task-promoting thoughts and reduction in task-demoting thoughts.
The aim is to foster clientsʼ belief that they can implement the requisite change
strategies, use them, and thereby see results.
Therapeutic homework in CBT for adult ADHD directly targets the relevant
life problems that necessitated treatment in the first place; it is the idea that
psychosocial treatment for adult ADHD operates at the functional level rather
than the symptomatic level (Ramsay, 2017a). Most adults with ADHD have
plans and goals that are feasible and desirable (although sometimes unrealistic),
but yet struggle to enact them. Cognitive strategies target the pivot point
between disengagement and engagement.
To this end, starting small and crafting early homework tasks for which there
is high likelihood of success is particularly important for adults with ADHD
(Ramsay & Rostain, 2015b). The goal is to not only promote initial success
experiences, but also illustrate that procrastination, disorganization, and other
issues occur in small matters in the same way as in larger, important matters. For
example, unloading a dishwasher, returning an impulsive online purchase, or
paying bills are useful initial targets. The way in which a client avoids unloading
a dishwasher entails the same issues as putting off a report for work. This view
opens innumerable options to practice and generalize coping strategies.
A useful takeaway reminder and analogy to reinforce this point (and illustrate
how unloading the dishwasher is in any way relevant to not getting fired at
work) comes from the 1980s movie The Karate Kid (Weintraub & Avildsen,
1984). The teenage protagonist, Daniel, seeks karate training from Mr. Miagi.
Before providing any formal lessons, though, Mr. Miagi assigns Daniel several
chores (e.g., painting a fence, waxing a car, sanding the floor), with precise
instructions for each one. When Daniel finally erupts in anger that he is not
getting the training he sought, Mr. Miagi reveals that each chore represents a
fundamental karate skill; Daniel had actually been in training all along.
Even the word homework may trigger noxious memories of past school
difficulties. Reframes such as field experiments, takeaway tasks, game plans,
action plans, skill practice, gathering experiences, or any preferred label
maintain the aim to improve life outside of therapy (e.g., “The other 167 hours
this week”). It is useful to normalize that imperfection and outright difficulties
with some tasks is expected as part of the learning curve—whatever the
outcome, there is a way to make positive use of it.

Define Terms/Specificity
Defining terms is a strategy typically used when clients refer to themselves in
critical terms, as a loser, a hopeless case, or as often heard from adults with
ADHD, lazy. Any term may hold a distinctive meaning for a client different than
a presumed definition, such as a client ambivalent about the intimacy she craved
in relationships. It was only when the therapist asked her to define her view of
intimacy, which the client described as “giving in to another person no matter
what they ask of you,” that new light was cast on the impasse.
It is a good practice to make sure the therapist and client are on the same page
and to inquire about clientsʼ definitions of terms and labels (e.g., “Being lazy
means that I know what I need to do, others seem to do it without a problem, but
I still just donʼt do it”). Specifying terms in this manner transforms a label from
a character trait into a cognitive behavioral matter, which is easier to address
(e.g., define the specific task you need to do, lower the bar to make sure it is
manageable). Socratic questioning by the therapist can also be used to flesh out
such issues—“If you told me you needed a pen to complete a form and I gave it
to you, but then you did not use it because you thought that it had no ink in it or
because you were not sure how to fill in the form and did nothing, is that lazy or
is something else going on?” Such negative self-attributions are common for
adults with ADHD, as these cognitions may have been implicitly and explicitly
reinforced by frustrations, comparisons with others, and, in some cases, labels
they have heard over the years, which fuel potential schemas.
Defining terms and specifying examples is particularly helpful when it comes
to task engagement for adults with ADHD. The reframing/framing of tasks
creates actionable steps, such as the smallest action a client can take to start or
“touch” a task, help to lower the bar so that the broader task is reduced into a
manageable engagement step, á la Mr. Miagi.
Another term to define is it, as clients will often say, “I canʼt handle it.”
Defining the it uncovers idiosyncratic meanings that create barriers to follow-
through. For example, after his boss had assigned a project during a face-to-face
meeting, a client became confused when reviewing his notes from the meeting,
as they were disorganized and incomplete (e.g., “They made sense at the time”).
The client planned to email his boss for clarification but later said, “I could not
do it.” When asked about the it getting in the way, the client said that he worried
that his boss would be annoyed at having to repeat instructions. He was
concerned he would be seen as incompetent, citing times his boss and others
were frustrated by his distractibility and disorganization. These issues were used
to disentangle and sort through the clientʼs mind reading of his boss, including
conceding that his boss might be frustrated, crafting the email, and accepting the
fact he needed the project details from his boss. The client was encouraged to
define his specific role in this situation (e.g., “Send an email requesting the
details I need to do my job”) and eventually sent the email. (Defining
terms/specificity is further discussed in Chapter 5.)

Perspective Taking
Apart from their many other effects, working memory deficits affect perspective
taking, which plays a role in manufacturing motivation for a delayed reward. For
example, most tasks require tolerating a degree of time-limited discomfort to get
started. Once on-task, discomfort often fades and opens the promise of achieving
a felt, visceral satisfaction of completing an objective or at the very least time
spent on task. Adults with ADHD are prone to impulsivity and escaping such
discomforting tasks, though. Perspective taking involves holding in mind and
acting on the alternative view that an individual can make headway and that the
initial discomfort will be short-lived, which draws on cognitive defusion (e.g., “I
can feel discomfort; it will pass once I start”).
Perspective taking is also useful when addressing the comparative thinking
common to adult ADHD, as was mentioned in the previous discussion of
everybody else/nobody else thoughts. Another variation on a classic perspective
shifting question is to use the example of a friend who has ADHD (e.g., “If a
friend of yours was in the same situation and had the same thought, how would
you advise him or her”). Clients are often more compassionate with others than
they are with themselves, including minimizing their personal need for patience
and self-compassion when managing ADHD.
A useful analogy to illustrate this idea is the plight of a left-hand dominant
person who encounters desks, scissors, sports equipment, stringed instruments,
and other items typically designed for right-hand dominant people. Left-hand
dominant people truly face more difficulties finding items fitted to them, but it is
worth the extra time and effort to find customized items, as well as accepting the
reality that sometimes they must simply improvise and make do with whatever is
available.
On the other hand, perspective taking can operate as a Trojan horse, a covert
justification for escape–avoidance. Decrees like “In the grand scheme of the
universe, what use is an essay on ‘Beowulf’ to a business major?” are invoked to
an individualʼs detriment. Therapists can adopt a devilʼs advocate role to gently
confront whether such perspectives are adaptive in a specific context, thereby
balancing the right of self-determination with ensuring clients are making
informed decisions: “Yes, the ‘Beowulf’ paper is not your lifeʼs work; but,
tackling it now will avoid your risk of working on it over break, taking an
incomplete, or possibly retaking the course. Ultimately, it is your choice, though
we can review tactics for handling it.”
Perspective taking and scaling, the latter referring to viewing oneʼs reaction
along a continuum help to identify exaggerated reactions and place them at a
more realistic point on a range (e.g., “Yes, reading ‘Beowulf’ is a chore, but is it
really the worst? How does it rank from 0 to 100? What could be worse? Is it
worse than compound fractures in both legs?”). Scaling the clientʼs discomfort
leverages a view that a task can be unpleasant and still tolerable. The clientʼs
ability to endure time-limited discomfort is a sufficiency reframe, rather than an
all-or-nothing view (e.g., “I can manage it” vs. “Iʼm not in the mood”).

Can Positive Thinking Be Problematic?

When discussing the aim of cognitive modification, the descriptor used is
adaptive thoughts, not necessarily positive ones, which is by design. A
misguided critique of CBT reduces it to the power of positive thinking. It makes
sense how this view may have taken hold as CBT came on the scene as a therapy
for depression (A. T. Beck et al., 1979). CBT for depression targets the signature
themes of hopelessness and pessimism, promoting adaptive optimism and
hopefulness coupled with behavioral activation to achieve improved mood.
Positive thoughts can be distorted, though, such as individuals with gambling
addiction ignoring laws of probability or individuals in a hypomanic/manic
episode minimizing the risks of reckless acts. Incautious optimism is an issue
relevant to escape–avoidance common to adult ADHD (Knouse & Mitchell,
2015; Knouse et al., 2019). Maladaptive positive thoughts are often coupled with
impulsivity, such as adults with ADHD who are prone to over commitment,
rashly taking on projects that are compelling, but which they cannot reasonably
fulfill (e.g., impulsive compliance; Ramsay & Rostain, 2015a).
Impulsive compliance is often fueled by enthusiasm for a novel opportunity.
Apart from difficulties saying no to others, positive feelings associated with an
invitation and the gratitude expressed by the asker (e.g., “Great! Youʼre the
best!”) reinforce a proneness to answer yes. There are many situations that can
be anticipated, but others arise unexpectedly. In either case, advance coping
strategies can be developed and practiced.
Interventions for incautiously optimistic thoughts, impulsive compliance, and
other maladaptive positive thoughts draw on interventions for impulsivity.
Impulsivity is a sequencing/working memory problem punctuated by
disinhibition, illustrated in descriptions such as “On your mark. Go. Get Set.” or
“Ready. Fire. Aim.” When faced with an interesting proposition, many adults
with ADHD have difficulties being able to pause, think through their existing
commitments (e.g., reflect), and judge whether it is feasible to take on the
responsibility (e.g., proflect). This process includes managing the decision pivot
point by either declining an offer or delay to allow for further deliberation.
Cognitive interventions challenge the assumption that clients have no control
over impulsivity.
A central skill for impulsive compliance is crafting a pithy coping response
for buying time. When invited to take on an obligation, adults with ADHD can
express interest but defer a final decision (e.g., “Iʼm honored to be asked to
organize the school fund-raiser but let me get back to you”). Having a stock
response helps to circumvent the assumed pressure to offer an immediate
answer.
This does not mean that an adult with ADHD will never accept any invites.
Buying time allows an adult with ADHD to ride out the initial impulse, mull
over an offer, and sort through any logistic factors and potential conflicts. This
delay allows an adult with ADHD to propose any conditions that would allow
him or her to accept the invitation without undue stress (e.g., negotiating a
deadline). There may be persistence on the part of a person trying to recruit the
adult with ADHD, such as using a combination of flattery, pushiness, pleas, or
outright guilt induction. An assertive take-away skill is that of the politician ploy
to “stay on message,” simply repeat the thanks, but no thanks script, including
the reminder that one need not justify a decision.
When addressing incautiously optimistic thoughts such as “I study best the
night before an exam,” guided discussions of the implications of this view help
to assess it (e.g., buying time with the client to sort it out). For example, a
therapist can ask, “Are there any potential difficulties with waiting until the last
minute? Do you have any other assignments that are due at the same time?”
Even if the client is confident in his or her plan to cram at the last minute, the
extended ripple effects on sleep and other domains of life should be considered.
Ultimately, clients have the right of self-determination, but a guided review
promotes informed decisions.
In fact, relevant to the discussion of maladaptive positive thoughts, there is a
view of ADHD being associated with a proneness for risk-seeking. Recent
research has disentangled the issue of risk-seeking from that of suboptimal
decision making, indicating that it is a deficit in the latter skill that results in the
former (Dekkers et al., 2018). Decision-making and problem management
interventions can be helpful in promoting adaptive choices.
There will be times that adults with ADHD (or anyone else) will be impulsive
or act imprudently. Apology is a commonsense strategy after an ill-advised act
to make amends, which can go a long way toward assuaging the effects of
impulsivity. On occasion, an adult with ADHD may have to resort to an after-
the-fact retraction of a promise. A reframe of this strategy is that for the
investment of a minute of discomfort, the client is saving himself or herself from
greater stress. Other facets of managing impulsivity are discussed in Chapter 5
of this volume.
Focusing on Strengths and Resources
Clinic-referred adults with ADHD in CBT are dealing with notable impairments
in at least one area of life, although they are usually facing stress and
impairments in other areas too. The management of ADHD through CBT itself
asks clients to sign on for a process requiring the use of various tools and
strategies. This can be viewed by clients as potential sources of failure and
frustration, noting that it is the difficulties with disorganization and follow-
through that created the problems that led them to seek help in the first place.
A role of therapists working with adults with ADHD is to reinforce progress.
Adults with ADHD are understandably prone to negative overgeneralization,
including when facing difficulties in CBT. An undone homework task or coping
setback is evidence that the client is “failing” at CBT just as they have “failed”
at everything else. This reaction is magnified by mind reading the therapist: “I
know my therapist is bored with me because Iʼm still struggling with
procrastination.” A useful approach is to normalize these slip-ups and reactions
as typical in the course of CBT for ADHD. Moreover, behavior change and
maintenance involves a process of taking several steps forward and a few steps
back.
An aspect of CBT for adult ADHD, though one that is often not as clearly
detailed, is exploring and cataloging examples of personal competence,
strengths, and aptitudes. The initial and primary CBT objectives target the
typical problem areas, the usual suspects in adult ADHD. However, there will be
talents or interests that clients may describe or explore during a course of
treatment that have been stifled by ADHD or sacrificed because of the time and
effort devoted to managing the effects of ADHD. Even within the impairment
domains, there may be aptitudes that have taken a back seat to the effects of
ADHD, including how the condition interferes with opportunities for clients to
display their best selves (see Sedgwick, Merwood, & Asherson, 2019).
Even problem areas may offer a glimpse into such positive characteristics and
qualities, such as a college student who tends to overcommit with clubs and
other duties. Although the student may work at being more discerning in what
she takes on, her passion for being active and involved can be reinforced and
leveraged in positive directions. An aspect of healthy coping is to ensure that
client get their recommended daily allowance of self-care activities, which
include personally valued endeavors. Such valued activities can be invoked for
therapeutic targets (e.g., “You are really good at keeping up with exercise, even
after a full day of classes. Are there aspects of your ability to do this that you can
use when facing assignments?”).
A concept that is familiar to practicing clinicians that is particularly relevant
for adults with ADHD is that of goodness of fit, the match of a clientʼs strengths
and interests with the corresponding expectations and demands of a setting. This
issue often arises when assessing the fit of academic and work situations (see
Lasky et al., 2016). Clients may find themselves encountering significant
struggles in a college major or work setting that go beyond the use of coping
strategies to manage challenging aspects of these endeavors. Instead, there are
essential demands of a field of study or career that are ill-suited for the goals or
well-being of an individual. The ostensibly straightforward task of finding a
better fit often runs up against comparative thoughts (e.g., “All my friends will
graduate on time,” “Iʼm almost 40—I need a career”). Although there will be
pragmatic issues related to finances and availability of jobs, focusing on
strengths, skills, interests, and other aspects of good fits often yield some
promising options or at least obvious poor fits to avoid.
Although CBT is first and foremost a clinical treatment undertaken to address
life problems, the recognition of skills and aptitudes is an important component
in its customization for adults with ADHD. Highlighting positive examples of
coping and the use of talents that may have been run asunder by the difficulties
associated with ADHD is another useful avenue of intervention, a variation on
the notion that there is nothing wrong that cannot be bettered by what is right.

CONCLUSION

This chapter reviewed classic cognitive interventions adapted for adult ADHD,
including the nuances of automatic thoughts and other mind-sets in clinic-
referred adults with ADHD. Cognitive interventions focus on enhancing the
ability of adults with ADHD to engage in and implement these tasks and
endeavors, including differences for how coping skills are framed and delivered.
Chapter 5 focuses on the use of these interventions in various real-world
contexts and situations faced by adults with ADHD.

KEY CLINICAL POINTS

There are various ways to identify and track cognitive distortions to

help clients become more aware of them. Different aspects of self-talk
provide novel ways to consider the influence of cognitions and operate
as an inhibitory intervention that allows for prolongation of the
immediate moment.
The defense attorney analogy is a tactic with which to implement
cognitive modification skills. Negative automatic thoughts are framed
as an argument made by a prosecuting attorney to the court. The defense
attorney serves as an advocate for the client to review the evidence.
Defusion strategies are a companion tactic with which to accept and
deenergize intrusive or distressing thoughts rather than trying to
suppress them.
Cognitive reframing is a useful cognitive skill for managing many
reactions that may involve a sense of insufficiency in adults with
ADHD and for reexamining whether adults with ADHD have
enough energy, focus, or time to complete a task rather than avoid
it.
The most common cognitive distortions encountered with adults
with ADHD include perfectionism, all-or-nothing thinking,
magnification/minimization, and comparative thinking.
The classic CBT cognitive interventions play an important role in
various other related change tactics. These include following through
on therapeutic homework or field experiments; defining terms and
specificity, particularly when addressing labels; perspective taking and
keeping reactions in proportion to events; managing difficulties related
to distorted positive thoughts; and identifying and making therapeutic
use of a clientʼs strengths and resources.
5
Cognitive Interventions in Action
Common Issues in Cognitive Behavior Therapy
for Adult ADHD

Chapter 4 reviewed many classic cognitive interventions and typical cognitive

distortions encountered in cognitive behavior therapy (CBT) and how these are
adapted to the needs of adults with attention-deficit/hyperactivity disorder
(ADHD). The focus of Chapter 5 is how these interventions are woven into
psychosocial treatment to tackle the functional difficulties faced by adults with
ADHD, particularly those related to escape–avoidance. The brainʼs reward
system is influenced as much by the anticipation of a reward as its achievement
(Sapolsky, 2017); therefore, cognitive interventions help adults with ADHD
frame and approach tasks so that they trust their ability to engage in them, which
is consistent with the self-regulatory efficacy cognitive theme.
This chapter is organized to introduce coping topics in terms of their typical
frequency of occurrence and priority for adults with ADHD in the course of
CBT. Such problems are not so easily compartmentalized, however, and there is
a great deal of overlap amongst these therapeutic issues. Managing
procrastination also draws on interventions for time management that are
influenced by impulsivity and emotional dyscontrol. The order of presentation is
debatable, but practicing therapists will find the central issues for adult ADHD
covered in this chapter. Chapter 6 reviews less frequent, but important, issues for
therapists working with ADHD.
 The review of common therapeutic issues facing adults with ADHD starts
with fostering engagement in treatment before tackling procrastination, starting
with a subset termed procrastivity. This review is followed by time management,
disorganization, and overlapping but distinct issues of managing emotions,
discomfort, impulsivity, and motivation/values. The review ends with
assertiveness and self-advocacy, addressing schemas, and handling difficulties
clients may have using coping strategies. This final issue is particularly relevant,
as adults with ADHD often struggle to reconcile and manage normative setbacks
encountered in CBT or any attempt at behavior change.
As in Chapter 4 of this volume, the interventions reviewed in this chapter
offer a menu for therapists and their clients. There is not a prescriptive order of
introduction of interventions or expectation that all of them will be used or found
useful by each adult with ADHD. Clients may find and rely on some favorite go-
to coping tactics or mix-and-match them to suit their needs. The measure of the
interventions is their utility in helping clients implement coping strategies to
improve functioning. Clients must engage in treatment to reap these benefits,
though.

ENGAGING IN TREATMENT

Late-identified adults with ADHD often need time to come to terms with their
diagnosis and its implications. An accurate diagnosis of ADHD can be
considered the first cognitive intervention because it provides a reframe for
making sense of longstanding difficulties and frustrations (Ramsay & Rostain,
2015b). This insight and prospect for change boosts hopefulness for many
clients, though others have an initial grief reaction as they reconsider their lives
through the lens of ADHD. Clients often wistfully (or angrily) reflect on how
their lives might have been different had ADHD been recognized earlier.
Witnessing clients process such grief reactions may provide hints of possible
schemas, if not fully formed examples: “For all this time I thought I was just
lazy, a screw-up.” A period of reviewing these reactions using accurate empathy
and psychoeducation usually allows clients to reach a point of readiness for
change.
Some adults with ADHD were diagnosed in childhood or adolescence but
continue to experience problems. They may describe unsuccessful attempts at
change in past treatments, through self-help and expert advice, or they may
disclose new life difficulties. They are likely on medications and have reduced
symptoms but realize “the pills donʼt teach the skills.”
Psychoeducation about ADHD as a problem of self-dysregulation helps to
normalize and make sense of these experiences. This framework gives a
neurobiologically informed explanation for the behavioral manifestations of
ADHD—“Here is why and how you struggle with disorganization.” Outlining
CBT provides a framework for how it can be helpful that may kindle hope for
change; what can be done about the why and how of ADHD. Clients can also be
encouraged to do their own research through reputable publications, ADHD
organizations, and online resources which provide credible information and a
sense of community. A full list of resources and organization is listed in this
volumeʼs Appendix.
Psychoeducation about the CBT approach includes the useful reframe that it
is a shift from managing ADHD to managing pivot points. This is not merely a
semantic twist but sets an important tone that the problems associated with
ADHD (e.g., procrastination, poor time management, disorganization) can be
sorted into specific, observable behaviors that lead to specific, actionable coping
steps that are more believable in terms of self-regulatory efficacy. This is not
meant to suggest that adults with ADHD are urged to “try harder” to be
organized; rather there are high-yield points between disengagement and
engagement or other moments when the timely use of coping strategies are
emphasized and targeted. Better use of coping skills fosters improved
functioning.
The notion of pivot points, itself, could be considered an intervention.
William James described the notion of now as constituting the “specious
present” (James, 1890). This point is a window of a few to several moments
representing the time span for certain actions (e.g., a handshake, a musical motif,
other brief events). The specious present is a yoke between the past and the
future, and people move through time on these pulses. It was described as “the
prototype of all conceived times . . . the short duration of which we are
immediately and incessantly sensible” (James, 1890, p. 631) providing an
increment of consciousness with “a bow and a stern” (p. 609). It is at this
fulcrum (and leading up to it) that cognitive interventions are likely most
relevant in addressing ADHD. Defining and targeting these influential windows
of opportunity, the synaptic cleft between abstract plan and visceral experience,
between not doing and doing, is the aim of CBT for adult ADHD to draw actions
more in line with intentions.
This pivot point view sets the stage for goal setting. This process involves
breaking down common goals (e.g., “I want to procrastinate less”) into more
specific behaviors. The notion of starting small involves eliciting immediate,
smaller examples of goals (e.g., “What is a recent example of when
procrastination was a problem for you?”). Even if the example is seemingly
insignificant, the point made is that people procrastinate on the small stuff the
same way as they do the big stuff. The skills for handling one task can be used
with all the others. Clients with ADHD are already prone to procrastination,
making it and other forms of maladaptive disengagement arguably the central
target in CBT for adult ADHD.

PROCRASTIVITY AND ADULT ADHD

Procrastivity refers to the phenomenon in which an individual makes a good-

faith plan to engage in a priority task, but when it comes time to perform the
task, engages in a lower priority (but still productive) endeavor (Ramsay,
2017b). Although procrastivity and other task delays can be adaptive at times,
the construct is used here to focus on the larger issue of procrastination as a
clinical problem that affects most adults with ADHD. Procrastivity is self-
defeating because the lower priority task, although useful, is not as time urgent
or important as the high-priority task and draws time and energy away from it,
increasing the likelihood the priority task will go undone.
Consider the example of a client who intends to work on their income taxes
on a Saturday morning well in advance of the April 15 tax deadline. Once
Saturday arrives, however, the client abruptly changes plans with a justification
(e.g., “The lawn is looking pretty high. I should mow the lawn now. I will mow
the lawn, then I will be able to focus on taxes”). If executed as stated, there is no
problem with this plan, whatsoever. However, what usually happens is after
mowing the lawn the client has other task-demoting thoughts (e.g., feeling too
tired) or finds other things that need to be done and justifies pushing off taxes to
tomorrow.
Procrastivity is not unique to ADHD but illustrates the distrust cognitive
theme of poor self-regulatory efficacy. Adults with ADHD become dispirited
(i.e., lose motivation) at the point of performance because of doubts of their
capacity to carry out the steps of an otherwise logical and feasible plan. This
thought and related feeling of discomfort result in procrastivity—jumping to a
task for which they view themselves as more able to manage. Adults with
ADHD will then criticize themselves for not keeping to what, in hindsight,
seems logical and feasible plan—the double whammy of negative thinking in
ADHD and procrastination.

Reverse Engineering Procrastivity

Because procrastivity promotes action and engagement, albeit to escape a
priority task, it is important to deconstruct exactly what it is about procrastivity
tasks (themselves likely a subject of avoidance in the past) that suddenly makes
them seem more doable when facing higher priority tasks. What can be gleaned
from them that can help adults with ADHD?
First, procrastivity tasks tend to be more manual or clerical, whereas higher
priority tasks are often mentally challenging and exact a greater cognitive load.
Each person holds a personalized algorithm for weighing the difficulty of
assignments, chores, and other tasks and his or her corresponding ability to
handle them. Tasks such as taxes or financial matters, homework, writing tasks,
and unfamiliar jobs with a potential for error (e.g., completing online student
financial aid form) are likely candidates for escape by procrastivity. Relative to
other tasks, these involve a degree of uncertainty about making progress and
reaching a desired outcome.
Even among competing high-cognitive-load tasks, there is an implicit rock–
paper–scissors scheme for determining their relative degree of difficulty (e.g., a
reading assignment is easier than a writing assignment, paying bills is easier than
an online financial aid form). These risk–benefit rules recall the behavior as a
commerce model in which actions undergo quick, nonconscious appraisals of
their time, effort, and energy costs (Henriques, 2011). Despite the logic of facing
higher priority tasks first, these tasks are often reflexively judged to be bad
investments and avoided, magnified by delay aversion and executive function
(EF) difficulties in adults with ADHD.
Second, with procrastivity tasks there is a better sense of what can be
accomplished within a window of time than for a high-priority task. There is a
clearer sense of cause and effect between the input of time, effort, and energy
and outcome for procrastivity tasks. A client who avoids taxes by mowing the
lawn might describe an image of working on taxes for hours and making no
progress, whereas the time and effort to mow the lawn is well known. This
predictability makes the procrastivity task seem comparatively more
manageable.
In fact, adults with ADHD may take on procrastivity tasks that require much
more time and effort than a priority task (e.g., 2 hours mowing rather than 1 hour
doing taxes). Clinical anecdote suggests that clients escape to procrastivity tasks
requiring more time and effort when they are confident (e.g., greater efficacy)
that they will achieve a desired outcome. A priority task, conversely, is viewed
as a potential source of frustration (e.g., wasted time and effort), which may
activate a degree of visceral, emotional discomfort. Therefore, it is deemed
better to devote more time and effort to an assured positive outcome than less
time and effort to an uncertain, potentially negative (discomforting) outcome.
Third, the procrastivity task, because it is often a familiar one, comes with an
existing action template or well-established routine that helps adults with ADHD
more readily start than the priority task. The client facing taxes may feel
disorganized and uncertain how to approach the task. This uncertainty creates a
degree of hesitation and unease, even in mild form, which opens a justification
for escape, fueled by a proneness for emotional dyscontrol and impulsivity.
The fourth and fifth elements of procrastivity are related. A procrastivity task
often provides a clearer sense of progress when compared with the priority task,
which is the fourth element. There are incremental markers that progress is
happening (e.g., a clear view of how much lawn has been mowed); the progress
on priority tasks is less clear (e.g., how much more time and effort is required to
complete a tax return, will previous steps need to be corrected before filing).
These examples bring us to the fifth and final element of procrastivity tasks,
which is that they offer a definitive, readily achievable endpoint that brings with
it a visceral sense of completion. Priority tasks often have imprecise, deferred
endpoints, perhaps because of unclear markers of progress. These jobs require
devoting efforts, often across time, without a clear sense of when they will be
done (apart from a deadline).
In the case of mowing the lawn, there is a hard stop offering a positive, felt
reaction (e.g., “Iʼm done mowing!”). Mowing the lawn may not be an
existentially fulfilling venture, but there is a positive feeling associated with
finishing the task. A deferred reward is an abstraction that is extremely difficult
for adults with ADHD to hold in mind and use as motivation. Although there is a
clear tax deadline (but not now), it may be unclear where one stands at any time
relative to the finish line, not to mention the allure of the wild card escape option
of a tax extension.

Lessons Learned From Procrastivity

Procrastivity is not unique to ADHD, but it and other forms of procrastination
likely occur more frequently and with more impairing effects for adults in this
population. Fortunately, the facets of procrastivity provide several useful lessons
that guide CBT interventions for adult ADHD.
The first lesson is to define a specific behavior that represents the smallest
actionable step, at least for engagement. This pivot point is one for which a step
is defined as something a client can do to move from being off task to being on
task, the synaptic step of turning intention into action. This step also navigates
the reflexive, visceral (emotional) discomfort, even in mild form, associated with
tasks and resulting proneness for an impulsive escape.
Using the tax example, an actionable first step is to collect all envelopes
marked as important tax documents or the digital equivalent. Carrying out this
action does not represent any appreciable progress on the central task, but,
especially for adults with ADHD, it is the essential engagement step of touching
the task—the task is now tangible and no longer an abstraction. Even if an adult
with ADHD stops after this step, he or she did not procrastinate, and taking this
step has exponentially increased the odds of taking more steps.
The second lesson is to outline ensuing steps, creating an explicit behavioral
script or recipe for the task plan. This turns the conceptual knowledge of what
needs to be done into actually seeing and doing a sequence of actions (e.g., “I
will take the tax document envelopes to my kitchen table, open them, and
organize them by category. I will then log on to the IRS website”). Such scripts
externalize, manualize, and sequence steps for engagement, akin to a this-then-
that approach. Scripting may seem remedial, but it is an accommodation for the
working memory and sequencing problems that are features of adult ADHD
(Barkley, Murphy, & Fischer, 2008).
Scripts may include steps for later reapproaching tasks that require multiple
work sessions. A final step of the current work session is to schedule a day and
time for the next work session. There may be different scripts for different tasks
at various points in a project (e.g., “Next time I work on my taxes, my first step
is to gather receipts for my work expenses”; “I will reread the last two
paragraphs of my essay I wrote last time”).
The third lesson is to set a discrete time frame for working on a task,
including a specific start time and a specific end time, ensuring the expected task
duration is realistic. This framing creates a bounded task with which to track the
flow of the task. The imposed parameter offers a time-based way to set up a
realistic plan and to track progress. A definitive endpoint provides a specific
target for calibrating effort and energy, including marshalling and extending
resources to “hold on” until the end (e.g., “Five more minutes, then Iʼm done”).
 Adults with ADHD may propose an open-ended work plan or large block of
time (e.g., all day; 3-hour block); however, these sorts of plans often reflect
maladaptive positive thoughts. When making task plans, these lofty notions are
reassuring placeholders that soothe immediate discomfort or stress (e.g., “Iʼll
take care of taxes on Saturday when I have all day to work on them”). This
example embodies the now/not now conundrum in ADHD—unless facing an
imminent and unavoidable task (“now”), it is a disembodied concept (“not
now”). People often do not do things they enjoy for 3 hours or all day. In fact,
facing a 3-hour or all-day work block is an overwhelming prospect that increases
risk for avoidance.
The strategy of creating a time-bounded task plan draws on the hard stops
offered by typical procrastivity tasks. The bounding is analogous to setting a
goal of swimming a certain number of laps in a pool. The defined endpoint
provides the wall at the other end of the pool that provides a reference point by
which individuals with ADHD can calibrate their time, effort, and energy
management (e.g., “Half a lap, then Iʼm done”). The bounding approach reflects
one of many ways to frame/reframe time and tasks to foster engagement, which
can also be used to extend effort (e.g., “I feel good, I can do one more lap”). This
lesson is particularly important for tasks requiring multiple work blocks to reach
a finish line for each increment, thus sustaining efforts across time.
The fourth and final lesson, which overlaps with time bounding, is to define a
doable behavioral objective for a task. Although time-bounding provides
benchmarks for progress and completion, it is useful to define a minimal
behavioral objective, such as reaching a certain step in the action script. Using
the tax example, an actionable objective could be to enter basic data on the
online tax form. Even if the objectives are quickly met, the behavioral
benchmark has been reached and efficacy is reinforced. The time-based and
behavioral objectives can be used together and create a whichever-comes-first
endpoint to achieve a point of completion.
Exhibit 5.1 lists the lessons of procrastivity, which provide ADHD-friendly
ways to approach tasks. They do not change the tasks but how they are framed
and defined, which likely improves self-regulatory efficacy. The next section
reviews the use of these and other strategies to address the broad-based
procrastination encountered with adults with ADHD.

EXHIBIT 5.1
Lessons Learned From Procrastivity
Procrastivity definition: Avoiding a higher priority task by engaging in a lower priority, less time-urgent (but
productive) endeavor that is ultimately self-defeating.

Facets of procrastivity tasks are that they

1. tend to be manual or clerical;
2. provide a clear sense of what can be accomplished in a window of time;
3. provide a series of familiar, actionable steps for getting started;
4. provide a clear sense of progress on the task; and
5. provide a clear endpoint with a definitive conclusion to the task.

Coping strategies developed from procrastivity for promoting engagement and follow-through are to
1. define the smallest, specific, actionable (manual) step to move from off-task to on-task;
2. define an ensuing sequence of behavioral steps or script to make them actionable;
3. create a bounded task with a start- and end-time, which allows assessment of progress on the task; and
4. define an achievable, task-based objective that provides a minimal target for the task, which can augment a time-
based endpoint.

MANAGING PROCRASTINATION: HOW YOU DONʼT DO THINGS

Procrastination has been deemed the “quintessential self-regulatory failure”

(Steel, 2007, p. 65). For clinic-referred adults with ADHD, procrastination ranks
as one of the most, if not the most, common problems. The lessons of
procrastivity (Ramsay, 2017b; Ramsay & Rostain, 2016a) inform many elements
of an implementation-focus in CBT for adult ADHD (Ramsay & Rostain, 2015a,
2015b). Many of these approaches overlap with and draw on research from
broader self-regulation interventions (Vohs & Baumeister, 2016) and
implementation intention strategies (Gollwitzer, 1999). This CBT approach aims
to help clients understand how ADHD interferes with their objectives of
understanding how they procrastinate or do not do things, thus defining
corresponding pivot points for coping.
A clinical tool developed for this end is the How You Donʼt Do Things
(HYDDT) form. The pivot points are presented in this section in the same order
as on the form, which serves as a takeaway reminder and coping tool.

Define the Overarching Goal and Its Value

The first step in tackling procrastination is understanding exactly what a client
wants to do and why. There is an array of issues that emerge at this stage that
may encompass any number of EF or motivational factors. A common barrier at
this step is sorting through and prioritizing among competing tasks. Mitch, a
college student with ADHD, sought CBT because of difficulties managing
college, specifically difficulties organizing and managing homework. An initial
pivot point that emerged was deciding which of several assignments to do first.
Another student may have a specific homework task but faces a sorority meeting
vying for her time. Both students have a task goal to do homework, but each
faces their own prioritization.
After defining a task goal, its value for the client should be reviewed. The
phrase do homework may connect with a desire to be a better student, pass a
class, or simply get it out of the way; such tasks also may hold other value (e.g.,
“I want to know that I can fulfill obligations even if they are not fun”), which
can be leveraged to promote follow-through. Whenever possible, it is good to set
up external reminders of goals and their values. These may be an inspirational
quote, an image, or a timer set for a time-based study goal. One client bought a
plastic toy button embossed with the word Easy that he would hit after finishing
an assigned chapter. The button operated as a cue for starting the task and a
reinforcing gesture for completing it.
Goal valuation is important to bring to the forefront of a clientʼs mind. A
nonclinical study about choice making when given personally relevant options
illustrated the role of orienting attention in the valuation process (Suri & Gross,
2015). In the study, there were opportunities for acting on priorities (e.g., healthy
vs. unhealthy food, taking stairs vs. escalator), and visible cues for priorities led
to better follow-through on actions consistent with these priorities than when
cues were absent. These types of externalized coping prompts and incentives are
recommended for adults with ADHD, who require more frequent, prominent,
and salient cues for them to be effective. (In some cases, ambivalence about
tasks represents broader therapeutic issues, such as an uncertainty about a
college major or the desire to be in college at all.) The next step involves making
the valued plan more actionable.

Redefine Tasks in More Actionable Terms

Clarification of an overarching goal and its value sets the stage for turning it into
a more defined action plan, specifically reducing it to a sequence of specific,
manageable steps. In the case of a homework assignment, an actionable task
definition specifies a particular assignment. In Mitchʼs case, after deciding the
economics homework was his priority, do homework was reworded as work on
Economics 101 assignment. Some individuals will find this to be an adequate
step for getting started, however for others, this step and definition still result in
a task that is an abstraction.
A more specific, actionable task is to answer questions at the end of Chapter
5 for Economics 101. This offers a clearer, more specific image of what needs to
be done, reduced to a manageable portion of work. This clarification is likely a
component of a broader homework goal that requires more detailed scripting
(e.g., “After finishing Chapter 5, Iʼll log on to the discussion board for
Philosophy class. Iʼll read posts since the last class. Iʼll consider ideas for my
required post”). While providing a clear-cut objective, even this level of detail
may not provide enough impetus for getting started. The next step involves
specifying the action step for a task that signifies moving from being off-task to
on-task: the engagement step.

Smallest Actionable Step of Engagement

After making a task goal more actionable, the next step is to tease apart and
define the smallest actionable, manual step that promotes initiation of the
actionable task plan. Even though there may be a perfectly feasible action plan
set out, there remains the need to navigate the pivot point from disengaged to
engaged. This may be achieved by highlighting the first step in the action
sequence or, in many cases, spending more time setting out a plan for the launch
sequence before getting to the task plan.
For Mitch and his economics homework, first steps related to the task script
might be to open Economics text and read questions at the end of Chapter 5.
Such initial steps need not result in progress on the task but still are helpful in
getting started (e.g., check the online syllabus to confirm assignment). Taking
this step does not mean that Mitch will complete or even start the homework, but
it helps lower the bar and shift from not doing it to doing it. In the case of adults
with ADHD, these initial steps may serve dual purposes as checking ensures
accurate information (e.g., that the homework is for Chapter 6, not Chapter 5).
Another manual first step for Mitch is to get to a study station (e.g., “I will go
to the library at 3 p.m. tomorrow”) or other examples that touch a task (e.g., “I
will get my gym bag,” “I will get car keys to run errands”), which help clients
get out of their head and into the here-and-now moment. These sorts of initial
steps are like dipping a toe into a swimming pool. The person is not yet
swimming but by simply touching water, the chances of swimming have
exponentially increased. Even arriving at the pool, wearing a swimsuit, and
finding a swimsuit at home all represent pivot points or ways to touch the task,
which makes the task visceral rather than conceptual and increases engagement.
Planning the engagement step also represents cognitive exposure and
rehearsal that serve a behavioral priming function to ready the client for this and
subsequent behavioral steps. The first step is designed to initiate a launch
sequence of other steps necessary for the task. Once started, the behavioral
sequence (e.g., the study script in the homework example) is likely familiar and
more actionable.
The task remains at risk for avoidance. Although the plan seems feasible
during therapy, there are many dissuading tasks competing for a clientʼs time,
effort, energy, and attention outside the CBT session. In effect, the client has the
coordinates for his or her task plan but must now navigate to this behavioral
destination, including steering through procrastivity and other distractions.
When and Where Will You Perform the Task?
Another priming step for a priority task is to have a plan for when and where it
will be performed and documenting this time (e.g., in a planner). This strategy
may also serve as the smallest step of engagement. As noted previously, this step
does not immediately address the task but initiates the launch sequence
connected with the desired outcome.
Mitch viewed his plan to go to the library after his last class let out at 3:00
p.m. as a feasible one. Scheduling the time and place at which a task was to be
performed provided a targeted plan to just get there. Walking to the library does
not get the assignment done, but it entails a necessary cognitive shift of going
with an intention of studying (“study mode”), even if done with a sense of
resignation or discomfort. Mitch adopted what he called “zombie
mode”—“Donʼt think, just walk”—to get to the library. He later recounted that
while walking to the library he felt more focused, felt less discomfort about the
task, and had a mind-set that he would get some studying done. He also saw
many other students walking to and seated in the library, which normalized the
fact that they had to study too.

How Much Time to Devote to the Task

The final task planning step on the HYDDT form is to set a realistic, bounded
time frame for a task (with a start time and end time). The start time for a task is
often established during the when-and-where discussion of an action plan, but it
is equally important to establish an end time. The objective is to set a feasible
and achievable time frame in which to perform the task and establish an
endpoint at which there can be a positive felt sense of completion, with self-
efficacy ratings and task completion being positively correlated (Bandura, 1997).
There is a bias toward making task predictions based on ideal circumstances
and an individualʼs best performance (Kahneman & Tversky, 1979) rather than
on typical conditions. Adults with ADHD may be inclined to set ambitious
expectations because of their desire to complete a task in one sitting in an effort
to contain stress and discomfort. It is advised that a time estimate not be based
on a clientʼs view of their best days (e.g., “There are times I get on a roll and I
can study for 5 or 6 hours”), but rather a more modest estimate to enhance
engagement.
Mitch planned to go to the library at 3:00 p.m. after his last class. His initial
plan was to study until 7:00 p.m., but the therapist wondered aloud whether 4
hours at the library after a full day of classes was too ambitious. After some
back-and-forth discussions about what constituted a realistic endpoint, Mitch
settled on staying until at least 4:30 p.m. but he retained the option to stay later.
This plan increased the likelihood of his hitting the target.
In this example, a time-based endpoint was used, but a task-based goal could
also have been used (e.g., completing at least two economics problems).
However, some task-based targets for academics (e.g., writing three pages) may
be variable in terms of the time they require to complete. A task-based approach
is handy for administrative tasks or those with clearer time and effort estimations
(e.g., a set number of online job applications). For other chores, item- or
location-based endpoints can be used (e.g., remove all dirty dishes from the
kitchen counter). As long as a client can give himself or herself credit for
keeping to the spirit of a task-based goal, they are a useful adjunct (e.g., “I wrote
two, not three pages of my paper, but I was productive”).
Being able to see the endpoint allows a client to calibrate efforts to reach it,
including using this focal point when persisting through difficulties (e.g., “Ten
more minutes until 4:30 p.m.; I can do it”). Adults with ADHD often run into
trouble when holding themselves to nonspecific, often unrealistic tasks and time
expectations (e.g., “Iʼm going to spend all day organizing the house,” “Iʼll skip
classes tomorrow and spend all day researching and writing my 10-page paper”),
which have a high likelihood of not working out as planned.
Two additional points can be made about this approach. First, viable
endpoints are benchmarks for progress on a task. Reaching each of these points
represents an accomplishment by itself. Positive feelings associated with getting
things done, even small tasks, are typically undervalued. The sense of
completion, for a single task and for cumulative tasks throughout a day, is an
important one for adults with ADHD, as it reinforces and provides evidence of
self-efficacy. Highlighting an endpoint and having externalized reminders for it
helps manufacture motivation (e.g., “How good will you feel at 4:30 p.m. when
youʼve met your study goal?”).
Second, this approach emphasizes getting started and making enough
progress. When reaching his defined endpoint, Mitch may be on a roll and keep
working on this or other assignments. Once engaged, a client can extend an
endpoint (e.g., “Iʼll keep going to the end of this chapter,” “One more problem
and then Iʼm done and can submit it”). These bonus scenarios are benefits and
consistent with the spirit of the interventions (but must be checked in the event
they are excessive, such as hyperfocus, and interfere with other priorities).
Personalized insights can be gleaned from these examples (e.g., “I can handle
a 2-hour study session,” “I work better in the morning; I need shorter work
blocks in the afternoon”). The bounded task approach is useful, if not essential,
for adults with ADHD who are juggling diverse tasks and obligations. Time-
bounded work blocks help to organize plans for budgeting time and switching
between different obligations and endeavors, including self-care and down time
activities.
At this point in the HYDDT process, there is a personalized, realistic plan
with which to counter procrastination. Attention now turns to potential
difficulties and distractions that may undermine these intentions. The image of
achieving a goal itself can be pleasing enough that it distracts from and interferes
with the actual execution of a plan (Oettingen, 2014; Oettingen & Cachia, 2016).
The strategy of mental contrasting involves defining goals and objectives
coupled with managing likely barriers to follow-through (Gawrilow,
Morgenroth, Schultz, Oettingen, & Gollwitzer, 2013; Gollwitzer & Oettingen,
2016). The next sections focus on identifying and managing barriers to the plan.

What Are the Barriers to the Plan?

Many adults with ADHD say that they are great at making plans but not at
executing them. The following sections answer the question posed to clients
after setting up a coping plan: “This plan makes perfect sense sitting here right
now. What could interfere with its implementation when you go to use it in the
real world?” This includes anticipating and planning for potential task-
interfering thoughts, feelings, and escape behaviors.

Task-Interfering Thoughts
“What thoughts could you have about the task and your plan that might convince
you to scrap it?” Some variation on this question elicits thoughts and images
clients already have or imagine they will have when facing the task. In the case
of Mitch, the question asked may be along the lines of, “Based on your past
experience, what thought will go through your mind tomorrow at 3:00 p.m.
when you are walking out of your last class to go to the library that could
convince you to do something else?”
Common thoughts that arise are that conditions (internal or external) are not
“right” or are somehow insufficient for effecting an otherwise feasible plan (e.g.,
“I might not be in the mood to study then,” “I might be too tired,” “The library
might be too crowded”), which lead to clients believing that they do not trust
themselves to do this right now. It is as much the interpretation of dissuasions as
it is their disruption (e.g., “Iʼve already wasted 15 minutes just getting ready to
study—this is pointless now”). These task-interfering thoughts occur within a
network of feelings (discomfort), impulsivity, and permission-giving for escape,
all of which conspire in nanoseconds to justify a comforting exit plan.
Cognitive modification interventions focus on anticipating, catching, and
evaluating these justifications, such as tweaking the ratio of positive-to-negative
anticipations of a task to a point at which it is viewed as doable. This pivot point
is where the idea of front-end perfectionism is relevant (Ramsay, 2017b;
Strohmeier, Rosenfield, DiTomasso, & Ramsay, 2016). Front-end perfectionism
sets unrealistic preconditions for a task (e.g., being in the mood, being
sufficiently focused). The adaptive view is that a client does not need to be in the
mood for a task, as no one is ever in the mood to study or work. Similarly,
examining sufficiency reframes that a client has enough energy and focus to
follow through on or at least attempt a task plan is like finding a gray area for
black-and-white thoughts (e.g., “Even if you are tired after class, will you have
enough energy to at least get to the library?”).
The defense attorney coping tactic interrupts, prolongs, and delays impulsive
justifications and escapes to think through a situation, including making use of
coping reminders, which can be useful to set out beforehand in anticipation of
facing potentially task-dissuading thoughts. Cognitive defusion tactics can be
used to note and accept task-demoting thoughts and any discomfort to persist on
a task plan. The initial (or anticipated) discomfort is reframed as a brief
investment of a few minutes in the service of the plan; additional skills and
mind-sets for managing these emotional issues are discussed next.

Emotional Interference and Discomfort

Cognitions related to not being in the mood for tasks are likely rooted in learned
emotional associations from past experiences for many adults with ADHD, even
in subtle form. Various tasks, obligations, and other mundane but necessary
chores are made more difficult by ADHD and thereby are linked to uneasy (if
not utterly aversive) feelings. These visceral sensations range from mild
annoyance to quasitraumatic reactions from past failure experiences and
impaired self-regulatory efficacy.
Adults with ADHD may have difficulties pinpointing any specific, overriding
emotional theme associated with a task or job. In fact, when untangling visceral
reactions to avoided tasks, they are often described as an issue of uncertainty
about a task and the related, nebulous discomfort from this uncertainty that
prompts escape–avoidance.
Although not a genuine emotion, the commonly encountered and
indeterminate feeling of discomfort described by adults with ADHD has been
termed ugh (Ramsay & Rostain, 2015a). The feeling is usually tied with a
thought along the lines of “Iʼm not up to doing this,” “Iʼm not in the mood,” or
“I donʼt want to,” suggesting aversion that prompts an impulsive escape. The
ugh concept (and other onomatopoetic utterances when facing irritating tasks)
strikes a chord for clients; the main idea being that facing a task, even one in the
service of a valued goal and outcome, is tied to some degree of visceral
discomfort and dispiritedness.
 Being discomfort-free is not a realistic precondition for most priority tasks,
particularly those associated with deferred rewards. Emotional management
strategies for adults with ADHD draw on basic mindfulness and defusion
principles such as recognizing and noticing feelings in a moment without
needing to dispel them (Zylowska, 2012). The tactics of observing and stating a
feeling and emotional labelling are associated with reduced firing of the
amygdala and better emotional management (Brooks et al., 2017; Lieberman et
al., 2007). These tactics provide a means for bearing emotions and distractions
by instituting a pause in experience in which to counter an instinctive escape.
Apart from any benefit these skills have on neurobiological networks, they offer
useful psychosocial tactics with which to navigate these moments rather than
giving up (e.g., “Iʼve been texting for 15 minutes. Okay, Iʼm off task and
frustrated. I can take some breaths, reread the problem, and ease back into my
work”).
Cognitive reframing is a useful coping approach that supports emotional
strategies, building on the notion that feelings do not need to dictate actions.
Emotions can be noticed, accepted, and tolerated while keeping to a task plan,
especially during the initial engagement steps (“Can you get to the library even
with the ugh?”). Defusion strategies are consistent with these efforts, the
acceptance of discomfort as an expected part of the pursuit of valued goals, a
willingness to do so even if not wanting to do so (Hayes & Smith, 2005). Facing
initial task discomfort is like getting into the pool and taking a few moments to
get acclimated to the water temperature before swimming.

Escape Behaviors
Finally, a therapist can ask a client, “What are the behaviors that will signal that
you are procrastinating?” or, using a poker term, “What are your tells for
procrastination?” Clients often cite behaviors such as texting, checking social
media, and excessive time on websites as common time thieves.
Although escape behaviors may fall into the category of procrastivity, there
are copious examples of nonproductive escape tasks (e.g., playing a game on a
phone or tablet, watching television, otherwise wasting time earmarked for a
priority task). These actions are often justified by statements like “I deserve a
break,” “Let me relax and then Iʼll be in the mood for the task,” and countless
others. Mitch said that he is at risk for “going down the rabbit hole” of news
websites during study time. His resolution was to put his laptop and smartphone
on airplane mode until at least 4:30 p.m., his planned end-time.
Tagging escape behaviors ahead of time helps clients to catch or avoid them
and stay on task. In fact, it is useful to differentiate between good and bad
breaks, as some bad ones (e.g., checking the news) run the risk of undoing the
plan, whereas good, bounded ones (e.g., get a cup of coffee) are more likely to
keep the person on track. Task planning also addresses risks by way of stimulus
control, such as when Mitch chose to study at the library rather than among the
distractions in his dorm room and put his gadgets in airplane mode.
In fact, behaviors that are escapes in the middle of a task (a bad break) can be
used as incentives for completion (e.g., “At 4:30 p.m., I will catch up on the
news”); although, after successfully completing a task goal, most adults with
ADHD describe being less likely to engage in them. This sort of this-then-that
coping skill is a manifestation of Premackʼs principle, the use of a more highly
desired activity to promote follow-through on a less desired one. This principle
is an empirically based staple of behaviorism that is familiar to any parent
making computer use contingent on a child completing homework. Predicting
justifications for escape and developing task-promoting thoughts is an effective
use of cognitive interventions.

What Is Your Implementation Plan?

The HYDDT form is like the self-regulatory exercise of mental contrasting
(Oettingen, 2014; Oettingen & Cachia, 2016). Defining a goal and
corresponding objective is more likely to promote action if coupled (or
contrasted) with plans for facing the real-world barriers to follow-through. The
use of implementation intention plans (Gollwitzer & Oettingen, 2016) was added
to mental contrasting to establish Mental Contrasting With Implementation
Intentions.
 Implementation intentions stem from research on the observation that a
purely goal-focused approach to behavior change does not inexorably produce
actions necessary to achieve that goal (Gollwitzer, 1999). Consequently,
specific, action-oriented plans tied to specific contexts (consistent with an
overarching goal) have been shown to improve follow-through. These plans are
framed in if-X-then-Y conditional statements in which a specific action or
obstacle is tied with a specific setting, such that the setting is a cue for a desired
action (e.g., “If situation X is encountered, then I will perform the goal-directed
response Y”; Gollwitzer & Oettingen, 2016, p. 223). Mitch developed an
implementation plan for getting back on-task in the event he got distracted (e.g.,
“If I get off track, then I will reread my answer to the current problem”).
Although not yet studied in adults with ADHD, studies in children with
ADHD show that these statements promote better follow-through when
compared with control participants (Gawrilow, Gollwitzer, & Oettingen, 2011a,
2011b; Gawrilow et al., 2013). The if-X-then-Y strategy has been a facet of the
CBT approach for adult ADHD and its implementation focus (Ramsay &
Rostain, 2008, 2015a, 2015b, 2016a). In a small open study of adults with
ADHD who completed CBT without medication, significant improvements on
an activation scale were achieved, consistent with this implementation focus
(Ramsay & Rostain, 2011).
Within the HYDDT framework applied to the case of Mitch, implementation
plans can be designed for the initial behavioral step of engagement (e.g., “If I
can get to the library, then I can review my economics assignment”). These
statements are particularly useful for managing the pivot points within a task
plan, such as defining the step for returning to the task after a brief break (e.g.,
“If I close the news website, then I can reread the last few sentences I wrote”).
Implementation plans can also be designed for reengaging in tasks after being
distracted, dealing with rationalizations for escaping a task, managing obstacles
(e.g., “If the main section of the library is crowded, then I will take the elevator
to the fifth floor”), or other vulnerabilities for deviating from the clientʼs
intentions. Implementation or if-X-then-Y plans, are useful take-away tactics,
including the use of possibility language, such as “when X, then Y.”
 Figure 5.1 provides a sample HYDDT form, which outlines the elements of
procrastination and space for developing coping plans. In the spirit of
personalized coping, many clients have specific go-to tactics. For others, these
issues may differ by type of task or setting. The form can be personalized as a
means for handling a clientʼs distinctive procrastination profile.
FIGURE 5.1. A Sample How You Donʼt Do Things Form

HOW YOU DON’T DO THINGS

Current task and overarching goal/value: (example: Write the monthly report; do well in my job)

Redefine current task in more actionable terms: (example: I will review the monthly data.)

Define smallest, specific, actionable starting point: (example: I will take my laptop to a coffee shop and start
by opening the data file.)

Specific time (start time and end time) and day this will be done: (example: Saturday at 9 a.m. until 10 a.m.)

Where this will be done: (example: My favorite coffee shop)

What might interfere with implementing this plan? Task-interfering thoughts? (examples: I have to be “in
the mood” to work on the report; I need longer than an hour; I’ll do other things today and then I’ll be able to
focus on the report tomorrow.)

What emotions/feelings might interfere? (examples: Pressure to make progress; worry whether I will get it
done; boss may find mistakes; ugh, I don’t want to do it; feeling too tired)

What are your escape behaviors/rationalizations that might interfere? (examples: I should do other work
first, then I’ll be in the mood to do the report; catching up on email and other work-related tasks; I deserve to
relax on the weekend.)

What is your implementation plan? (example: If X, then Y—If I can get to the coffee shop, then I can open
the data file.)Hopeful plans for living and for the future:
 It is important to keep in mind that procrastination also interferes with
meaningful personal undertakings that are vital to well-being and sense of self.
Procrastination is a meeting point for the EF difficulties faced by adults with
ADHD—there are many ways to not do things, including poor time
management, which is discussed next.

TIME MANAGEMENT CHALLENGES

Time is the most commonly used noun in the American English language
(Burdick, 2017). Time management or, more specifically, organizing behavior
across time, is a core problem area for adults with ADHD. Temporal myopia
signifies the recurring nearsightedness (or time blindness; Barkley, 1997) that
undermines planning, organizing, and sustaining behaviors toward long-range,
high-yield goals. This concept is also captured in the now/not now dichotomy
commonly described by adults with ADHD, where a priority matter resides in
the not now category until it becomes imminent and urgent, vaulting into the
now category. Consequently, many tools and strategies are better devoted to
helping adults with ADHD to better organize and manage time and tasks, as is
discussed next.

Organizing Time
Typical time management strategies include tools, such as calendars, daily
planners, to-do lists, and visible time pieces, with which to track the flow of
time, from minutes and hours within a particular day, to the flow of days across
a week and beyond. Such tools are “time machines” that allow adults with
ADHD to see time in increments with which to map out and parse their
behavioral plans. Planners and calendars are essentially series of empty columns
and rows that divide up time in visible segments of varying specificity (e.g., 15-
minute segments, hour-by-hour, day-by-day, week-by-week). Not only a device
with which to make task appointments, these visuo-spatial representations also
provide a means for tracking where someone is in time relative to his or her
schedule and plans.
Cognitive reframing is useful in time management to help individuals with
ADHD view time devoted to a task in more adaptive ways. These modified
views have ripple effects on other elements of time management, such as the
effort and energy required of a task. In fact, judging time is an area where
distorted positive thoughts often arise.
A basic time management recommendation is to devote a portion of time
each day to plan out the dayʼs schedule. A suggested guideline (that can be
personalized) is to spend 10 minutes setting out or reviewing a plan for that day.
However, the phrase 10 minutes is often merely a euphemism for an
indiscriminate, brief span of time. Individuals with ADHD may intend to set up
a dayʼs plan, but have the thought, “10 minutes is not that much, I can do this
later,” then do not get around to it. This is a quintessential example of how a
seemingly trivial delay triggers a cascade that ends up in the frustration of yet
another mismanaged day.
From a linguistic standpoint, 10 minutes is a whole substance or chunk; the
same time can be reframed as 600 seconds, which is a shift to small particles
(Pinker, 2007). Although identical, reframing minutes as seconds creates a
cognitive shift as the latter seems a more manageable time investment.
Variations on this time framing for tasks, such as a 5-second rule (Robbins,
2017) up to a 10-minute rule (Ramsay & Rostain, 2003), cluster around the
notion of the smallest bit of time that can be tolerated to engage in a task.
Before the advent of the World Clock, international time zones, and wearable
timepieces, time estimates were given in terms of familiar tasks, such as “Iʼll be
with you in a milking-of-a-cow” (Johnson, 2014). In fact, there is a line of
research using a striatal beat-frequency model of temporal discrimination or the
learning of useful durations of time (Burdick, 2017). The model holds that an
individualʼs sense of time is tied to learned chains of behavior in actual tasks
(automatic, habit-based processing). In a similar vein, such time reframes can be
drawn from clientʼs experience to facilitate task follow-through, like planning
the day. For example, the 10 minutes devoted to planning the day can be framed
as the time it takes a student to walk to the cafeteria, the length of two songs by a
favorite musical artist, or the length of a television commercial break. These
reframes offer analog, concrete, visceral feelings of time that may be more
palpable than clock times (“Can you can spend the length of two Jack White
songs to plan your day?”). The Pomodoro technique (Cirillo, 2006/2018) is a
system for breaking down tasks into increments, aided by timers and apps to
externalize reminders.

Sustaining Effort and Energy Across Time

Time management includes effort and energy management, the pacing of an
individual over time. This section focuses on thoughts about the perceived
demands of endeavors and self-regulatory efficacy for meeting the effort and
energy demands. As noted in Chapter 1 of this volume, people automatically
judge the cost–benefit of tasks to determine whether they are worth the
investment relative to the result (Henriques, 2011). ADHD makes many tasks
seem to be bad investments, despite their logical value.
This facet of time management is closely connected to how a task is defined,
not unlike how time is framed or reframed to be viewed as manageable. Seeing
as time, effort, and energy are conceptualized here as being a related bundle, the
example of planning oneʼs day will continue to be used as an example. As with
time, the cognitive task is to frame effort and energy in manageable allotments
such that adults with ADHD can adequately assess their sufficiency to these
demands to enhance engagement (or make an informed decision to defer a task).
To determine the effort required of various plans throughout the day
(including the effort required for planning itself), tasks are dissected into
specific, behavioral steps. Queries such as “How would you describe what you
have to do if you were writing a recipe for this task?” or “How would you
program a robot to do this task?” help to transform an overarching, potentially
overwhelming task, into a series of actions. This exercise also serves as
cognitive exposure, facing and thinking through the task, as well as prolongation
in EF terms. In the case of planning the day, the script might be to access the
planner, record and review existing commitments, and consider how to use
remaining discretionary times.
Therapists may run into a Goldilocks problem with some clients getting
distracted by overly detailed itemizations of plans and others still defining them
so broadly that they overlook important pivot points. Guided inquiry about the
utility of itemized plans and anticipations of how they will unfold in real time
can help reach a point at which the estimations are sufficiently right for a client
with overly detailed plans (e.g., “That recipe is comprehensive but it looks
daunting at first glance. Do you think it will be more likely to help you get
started or will the details be distracting when you use it?”) or a client with overly
broad plans (e.g., “You have ‘get up and out the door to work’ as a first step.
Seeing as leaving your house on time has been a problem area, are there any
smaller steps within that one that would be helpful to specify?”).
Fortune telling cognitions may emerge about efforts on planned tasks (e.g., “I
might get stuck on my assignment”). This anticipatory distortion predicts
problems that are statistically possible but unlikely or at least are manageable. A
coping maxim is to not let possibilities get in the way of the probabilities
associated with task engagement. Anticipatory problem-solving can be used to
craft if-X-then-Y plans for handling possible snags (e.g., “What could you do if
you have problems with the assignment? Can you contact the class TA or
professor or go to office hours?”).
These anticipated snags may appear as visual images of wasted time and
effort/energy (e.g., “I can see myself sitting here all afternoon doing homework
without making a dent”), although framed in all-or-nothing terms, there may be
some truth to these views for clients facing a backlog of work. Even painstaking
efforts over a weekend might not lead to fully catching up on tardy homework or
a buildup of chores. Clients may rely on massed effort and marathon work stints
when facing a deadline, which is the default, last-ditch option for facing overdue
work to limit the effort and discomfort to one agonizing sitting.
Distributed effort, on the other hand, focuses on segmented task goals such as
selecting and starting on one overdue assignment or household chore to make
progress. A useful reframe is that whatever small step is planned “will have to be
done at some point”; overdue tasks as a daunting whole can be thought of being
composed of pieces. Seeing and believing and trusting the value of small efforts
is important for adults with ADHD, particularly for projects that will have to be
picked up and set down several times. Portion control of effort on longer-range
plans can be tracked by crossing items off a list or simply using the planner as a
record of times devoted to a project, logging tasks accomplished, and planning
next steps. Distributed effort also benefits from recruiting a helper such as a
study buddy or bartering with a friend (e.g., “You help me organize my kitchen
and Iʼll help you with your closet”).
The idea of distributed effort is used to break down tasks or projects across
time to meet a deadline or achieve some sort of other objective. The
choreography of different task demands throughout each day and across a week
also gets at the issue of energy management or self-regulatory endurance. As is
said of soccer players, good players find their rest while on the field.
Cognitive distortions about energy arise in two related ways for adults with
ADHD. The first is the now familiar sufficiency judgment of whether a client
has enough energy for a task. Periodic tiredness, fatigue, or a malaise after
finishing a task when there is not a clear sense of what to do next, and other
examples of the ebbs and flows of energy throughout a day are perfectly normal.
However, all-or-nothing reactions of “Iʼm too tired” or some manner of “Iʼm not
up to it” run the risk of justifying disproportionate, self-defeating avoidance.
The second and related aspect of the sufficiency thought is the view of a
clientʼs energy as a finite resource like the gasoline in a car; it must be conserved
to keep from being completely emptied. An ebb in a clientʼs energy activates
escape thoughts when facing a planned, realistic undertaking (e.g., “Iʼm too
tired. Thereʼs no way I can do this now. I have to rest”), which is self-defeating
when it undermines reasonable follow-through.
This is not to say that an adult with ADHD should not take breaks, have
pockets of down time, or occasionally call it a day earlier than planned.
Adequate rest, sleep, and discretionary time should be priorities in a clientʼs
schedule. It is not only duties such as work, school, or chores that fall prey to
assumed lack of energy, but also activities that foster happiness and well-being.
The therapeutic issue is effective energy management and ensuring such choices
are informed decisions rather than avoidance.
Energy management cognitions play a role in task engagement, often when
exiting rest mode to enter work mode, but also when switching between work
tasks. Such transitions are sensitive windows (pivot points) of time for adults
with ADHD because they are leaving a task with which they have successfully
engaged and presumably made some progress (or was a pleasant diversion) and
now face the prospect of gearing up for another task, which holds its own
onboarding challenges. Hence, any sense of weakness or insufficiency in terms
of energy increases the likelihood of avoidance or escape. These reactions can
fuel justifications in the form of outwardly logical permission-giving thoughts
(e.g., “I did a good job and I deserve a break”). There may be a subtle desire to
end on a high note after a having already tackled a task on the basis of
instinctive, unspoken mistrust beliefs (e.g., “I finished this task. I was on a lucky
roll and Iʼm due for my luck to run out, so better for me to stop while Iʼm feeling
good and productive”).
Cognitive interventions reframe the energy needed for a task from a requisite,
“optimal” level (which sets the stage for an insufficiency view) to a view that a
client has enough energy for a task. The strategy of scaling energy to specific
actions is also useful. This entails viewing energy along a continuum, like the
battery level on a smartphone, and assessing how much energy is required (e.g.,
“Do you have to be at 100% to get started?” “If your phone battery was at 50%,
would you still use it?”). These modifications challenge all-or-nothing views and
establish a sense of enough energy and making good use of it. These adaptive
thoughts are bolstered by time management tactics, such as creating a bounded
task for calibration of energy for engagement (e.g., “Do you have enough
energy—enough bars on your battery—to read the math problems and see what
you can do in 30 minutes?”).
The concept of generating energy is a counterpoint to that of energy as a
finite resource. An example of a car with a dead battery can illustrate this point.
After a dead battery is jump-started and the engine is running, the car is not
immediately shut off to conserve energy but is driven for a time to fully recharge
the battery. The idea of generating energy through action is a handy one for
clients challenging distortions such as “Iʼm too tired to go the gym” with “How
often have you seen people fall asleep in spin class?” Socratic questioning about
this issue usually uncovers clientsʼ experiences with sparking enough energy for
a task (“I know that once Iʼm at the gym, I rally”).
The energy facet of time management also pertains to the choreography of
tasks. For example, some people plan time early in the day for work that exacts a
high cognitive load, a time when they feel sharper and more galvanized. After
facing these mentally demanding tasks, they switch to administrative duties,
face-to-face meetings, or other tasks that are more hands on, which exert less or
a different cognitive load. This switch offers a welcome change of pace that uses
a different energy, even if not representing a true break. On the other hand, there
are some tasks that can be reasonably performed even in low energy mode that
are planned for other times of the day. A person might not expect to work on a
monthly report at 11 p.m., though mindless chores or readying work items for
the next day are reasonable at that hour.
Another aspect of energy management is tending to energy needs throughout
the day. Research on willpower, a construct comparable to self-regulation, has
fostered a view of it as a muscle that can become fatigued and less efficient
(Baumeister & Tierny, 2012). Self-regulatory difficulties characteristic of
ADHD render clients more prone to not only willpower fatigue but also mental
and physical fatigue (Guntuku, Ramsay, Merchant, & Ungar, 2019; Rogers,
Dittner, Rimes, & Chalder, 2017; J. L. Young, 2013), which may magnify
coping difficulties.
The basic means for bolstering energy and recharging the self-regulation
battery include adequate sleep; a healthy diet; regular exercise; positive, goal-
directed self-talk; healthy breaks between tasks (including mindfulness
exercises); and incentives and other emotional boosts for task completion. All
these self-care domains, though, are problem areas for adults with ADHD
because they require self-monitoring, planning, and follow-through to reap
benefits. Conversely, unhealthy, if not harmful, habits deplete energy and coping
resources.
In terms of other energy management strategies, many clients carry protein-
rich snacks and water or sports drinks with them for when they notice their
energy flagging. Opportunities for walking, like during work breaks, help
integrate physical activity and mental breaks in the day, as well as activities that
may be already established in a clientʼs schedule (e.g., exercise classes,
mindfulness practice, hobbies). Adults with ADHD must guard against the
tendency to forego these self-care activities as a self-imposed ADHD penalty
because of coping difficulties (e.g., “I cannot justify going to yoga class when I
have not gotten anything done at the office”). Self-care is a good target for
treatment that supports ADHD management and well-being.
A planner can be used to establish times for activities as well as periodic
breaks in oneʼs day when there is a pause and chance for respite. Similar to
having an endpoint for a task, breaks and transition times in a schedule provide
bounded reference points when a person can recharge. Breathers in a schedule
may include lunch, a planned coffee break, a train ride home, sitting in the car
waiting to pick up children, yoga class, or undedicated down time. Periodic
rogue, scheduled days off from work or scheduled events on the calendar offer
valued markers. If nothing else, simply being able to hold on until reaching these
anchor points helps break up the day, week, or month into portions.
There are many effective time management tools and strategies for adults
with ADHD. The cognitive elements of the framing of time, effort, and energy
are necessary steps for using these tools, but their use can be undermined by
disorganization (e.g., misplacing a planner). Organization, the focus of the next
section, is another aspect of managing ADHD often tied to time management.

ATTITUDES ABOUT ORGANIZATION

When describing disorganization problems, many adults with ADHD are usually
referring to difficulties organizing behavior across time, such as juggling
different tasks and other time management issues discussed previously.
Disorganization also refers to processing difficulties (e.g., expression of thoughts
and ideas) as well as sequencing behaviors for enacting a plan (e.g., scripting).
However, disorganization most often refers to problems managing the various
“stuff” of life, such as coping tools and information in different domains of life.
Thus far, the emphasis of this chapter has been on defining specific tasks and
plans to foster engagement and follow-through. Organization is treated using the
same scaffold but focuses on establishing habits and basic tools for routinizing
many foundational demands of daily life. Again, implementation is key.
Reviewing a clientʼs belief in or self-regulatory efficacy for the typical
organizational approaches augments a skills-based approach to personalize and
improve behavioral follow-through.
A first common step is establishing homes or a launch pad (Kolberg &
Nadeau, 2017) for the essential tools of daily life. Setting a consistent location
for keys, a phone, a wallet/purse, and other needed items is important. This
home is the place for action objects for later use or for priority items such as
homework, an umbrella, a gym bag, a prescription, and so forth.
It is easy for adults with ADHD, though, to minimize the importance of this
pesky step because it is annoying and thereby prone to rationalizations (e.g., “Iʼll
put my keys away later. One time wonʼt hurt”). This inconsistency coupled with
working memory difficulties make it hard to remember to remember where
items were placed. The issue for many adults with ADHD struggling with
disorganization is that the time, effort, and energy devoted to tracking down
needed items is often compounded by the ripple effects from other stressors,
such as looking for items while already running late for work or class. Similarly,
a misplaced planner or other item may have cascading effects for a commitment
or procrastination later that day.
Cognitions related to consistently placing items in a home base (or similar
habits) often revolve around “should” or more specifically, “should not”
statements (e.g., “I should not have to be so compulsive about keeping these
things in one place”), as well as magnifying the hassle factor involved in such
routines (e.g., “I have to go all the way back upstairs to put my keys away”).
Normalizing and reframing the benefit of these routines as well as the fact that
the hassle to maintain them is minimal helps to promote follow-through, which
can be reinforced with the use of coping reminders.
Organization skills also are used to manage other possessions such as
clothing, kitchen items, and various files and other tangible articles. Common
complaints refer to clutter, untidiness, or incomplete processes such as baskets
full of clean but unfolded laundry. Time and procrastination management skills
are used to prioritize and schedule specific tasks, either individual tasks (e.g.,
folding and putting away clean laundry) or upholding systems for recurring
chores. Such manual tasks are generally low cognitive load undertakings that can
be performed in low energy mode, usually with predictable and positive results.
Moreover, they can be paired with enjoyable tasks, such as listening to music or
podcasts. In fact, it is important to be on guard for the fact that these sorts of
tasks that may be innocently recruited as procrastivity tasks (e.g., “Iʼll do
laundry first; then Iʼll focus on studying”). Framing chores as time- or task-
based endeavors with bounded endpoints that can be done while enjoying some
form of media fosters task-promoting mind-sets and follow-through.
Managing information is another organizational issue, particularly gathering
and accurately recording important information. The information may be class
notes, work assignments, appointments, or promises made to friends. As
discussed in a later section, interpersonal skills are underused for managing
ADHD. Simple steps of asking someone to repeat something, repeating back
what one has written down to make sure it is accurate, or reaching out to
someone later for clarification are coping skills to ensure a client has needed
information. Making use of or advocating for additional resources, such as
teacher office hours, meetings with a supervisor, or check-ins with a spouse also
help ensure one is on track with endeavors. Table 5.1 lists some skills used for
managing attitudes about organization.
A barrier to the use of organizational and other skills is negative feelings
about them. The management of visceral feelings of discomfort and other
emotions associated with tasks is essential in terms of thoughts, which is covered
in the next section.

TABLE 5.1. Managing Attitudes About Organizational Skills

Organizational strategy Maladaptive thought Adaptive thought

Using a home for keys, wallet, “It is a hassle to put things “I can set up a home near the door to make it
smartphone, and other essential away right when I get easy.”
items home.”
“I do not want to have to do this but I am
“I should not have to do willing to develop this habit to avoid more
this.” hassles.”
Scheduling chores “By the time I get around to “I have enough energy to do the steps. I can
doing the chore, Iʼm too listen to music while I do it.”
tired.”
“If I can take the first step, I can get started and
“I will wait until I am in the last for 10 minutes.”
mood to do it later.”
Entering tasks in a daily planner “I should not have to be so “Planning helps me get things done and have
rigidly detailed.” more free time.”
“No one else must do this.” “I do not know what others do. This works for
me to stay on track and feel better.”

EMOTIONAL MANAGEMENT DIFFICULTIES

Emotional dyscontrol is a core feature of ADHD despite its total absence from
diagnostic criteria (Adler et al., 2017; Barkley, 2015b; Kooij et al., 2019). These
affective issues are different from the common coexisting emotional disorders.
Emotional dyscontrol in ADHD manifests as relatively short-lived but sharp,
disruptive reactions to stressors, such as problems downregulating emotional
reactions and upregulating adaptive emotions necessary to manage a stressor or
face a task. These triggers are of the sort that would elicit emotional reactions
from anyone but are more disruptive and distracting for adults with ADHD.
There are many facets of emotional management, including dealing with
specific situations and changing or leaving a setting, attentional deployment or
what is attended to, cognitive appraisal or managing interpretation of events, and
managing reactions to events (McRae, Ochsner, & Gross, 2011). Recognizing
and acknowledging the clientʼs current emotional state is a good first step, even
if only to take notice that he or she is feeling upset or bothered. Identifying and
stating the current emotion reduces amygdala activity (Lieberman et al., 2007).
Emotional labeling is a similarly portable and easy-to-use coping activity with
which to modulate feelings (Brooks et al., 2017). Much like catching automatic
thoughts, these emotional check-ins (e.g., “How or what am I feeling?”) create a
pause and opportunity for coping.
 The process of naming emotions can be aided by coupling it with a
corresponding cognitive theme (A. T. Beck, 1976; Burns, 1989). Some relevant
emotions for adults with ADHD (and corresponding cognitive themes) are
anxiety (perceived risk, uncertainty), anger (unfairness), guilt (having done
something wrong), and shame (being less valued as a person). Whatʼs more, the
concept of emotional granularity (L. F. Barrett, Gross, Christensen, &
Benvenuto, 2001; Smidt & Suvak, 2015) suggests that more precise emotional
labelling promotes better emotional management. An example of this is not only
recognizing an apprehension about homework but labelling the feeling as “my I-
donʼt-want-to-work worry.” Minimal emotion labelling is enough for greater
emotional clarity and plans for coping, though not necessarily follow-through by
itself (Vine, Bernstein, & Nolen-Hoeksema, 2019).
In addition to these reactive cognitive strategies, proactive steps can be taken
to face situations that are typically emotionally activating to adequately prepare
or perhaps avoid them. Clients can identify risk factors (e.g., hunger, time of
day) that may interact with high-risk situations (e.g., long lines, critical
feedback) to stir untoward emotions. Personal cues or tells that a client is upset
are also helpful (e.g., clenched fists, tone of voice, being short with others) as
they signal the need to use coping skills. Stress management and mindfulness
skills for top-down regulation can be used daily to tend to feelings (Mitchell et
al., 2017; Zylowska, 2012) and gain greater perspective and emotional
endurance for handling typical hassles. These day-to-day practices help to
domesticate feelings (Taleb, 2012), by which they are recognized and
experienced (accepted) but do not overwhelm intentions. This process can
include mind-sets of gratitude and positive feelings.
Working memory difficulties create problems recalling effective options for
handling emotions. Crafting a set of go-to reminders for positive coping or
having readily available emotional coping cards, notepad, or a physical reminder
(rubber band on wrist) can be helpful. Self-care, exercise, and other good habits
also support emotional management. Field experiments offer chances to actively
practice skills such as mindfulness. Together, these skills modify the thought
that an adult with ADHD cannot control their emotions, an important cognitive
shift.
Such emotional management strategies help adults with ADHD better handle
affectively provocative situations. However, Bandura (1997) noted that “the
activities of everyday life are strewn with frustrating, boring, stressful, and other
aversive elements” (p. 63). Therefore, the ability to manage discomfort is
arguably the skill most relevant to managing adult ADHD.

TOLERATING DISCOMFORT: TAMING THE UGH

Tolerating discomfort, the ugh feeling, has been proposed as the key emotional
target of CBT for adult ADHD. This discomfort is reciprocally determined from
the effects of ADHD on functioning. Repeated frustrations become associated
with negative feelings and self-doubts (mistrust) that punctuate engagement and
follow-through on tasks and roles. These gut-level, evident, but nameless
feelings are often expressed as onomatopoetic syllables (ugh, bleh, meh), telltale
signs of aversion. Goal-focused behavior requires persistence of effort for
relatively little immediate benefit and often short-term costs. Switching between
tasks, keeping up with assignments, tense moments with others, and other
matters of adult life all involve a degree of unease, the handling of which is a
core facet of self-regulatory efficacy (Bandura, 1997). Ugh feelings can be
magnified by schemas, as such feelings that may be tied to self-mistrust that
forewarn of potential failure (or at least discouragement).
Ugh feelings and related discomfort have been addressed previously and as a
facet of overall emotional management strategies. There are many cognitive
distortions related to discomfort, such as emotional reasoning (e.g., “I must be
discomfort free to do this”), comparative thinking (e.g., “No one else struggles
with such feelings”), and all-or-nothing thoughts (e.g., “If it feels bad, it must be
bad”) that justify escape–avoidance. However, these thoughts are amenable to
reframing the relationship with emotional discomfort and simply developing
adaptive alternative thoughts; in fact, discomfort can be reframed as a cue for
facing high-value, high-yield tasks—these feelings signal their importance and
relevance.
 Drawing on progressive exposure interventions for anxiety, cognitive
defusion, and other elements of acceptance and commitment therapy (Hayes,
Strosahl, & Wilson, 1999), accepting discomfort is seen as a commitment to a
personally valued endeavor. Facing the initial discomfort is reframed as a time-
limited challenge and opportunity—“Can you manage the ugh for a minute to
see if you can get engaged? Could you hold your breath for a minute? How will
you feel after you get started?”
Cognitive defusion strategies are particularly relevant for managing such
affect, as such discomfort is closely tied to cognitions along the lines of “I really
do not want to do this” or “Iʼm not in the mood to do this.” The notion that a
client can entertain such feelings and thoughts about tasks while still engaging in
them is useful across the board for coping with ADHD, the idea that clients can
be willing to face their feelings though not wanting to do so (Hayes & Smith,
2005).

REINING IN IMPULSIVITY

Of the symptom domains of ADHD, impulsivity is the outsider, clumsily paired

with hyperactivity. Impulsivity is relevant for adult ADHD, particularly its
overlap with emotion regulation. Impulsivity is essentially acting on an
overriding whim without forethought. It is not a stretch to infer that emotions
contribute to the whim or urge to act that, in the case of ADHD, tramps over
already fragile inhibitory skills. Impulsivity is a distinct factor in procrastination
(Steel, 2007, 2011), perhaps operating as a preemptive escape at the first hint of
emotional discomfort (e.g., ugh), launching an escape–avoidance program to
avoid further possible discomfort and failure when facing difficult tasks. A
connection of impulsivity and emotions is consistent with the hot EFs used to
manage pressing, affectively laden situations.
So, managing impulsivity is a priority issue for adults with ADHD. But if
impulsivity is acting without thinking, what good are cognitive interventions?
Cognitive strategies target the all-or-nothing thought that “I cannot control my
impulses.” Antecedent control is more effective than reining in already activated
behaviors and emotions. Therefore, coping strategies target a clientʼs impulsivity
profile, the high-risk situations in which he or she is prone to have troubles (see
Chapter 4, this volume).
Risk factors for disinhibition include settings associated with boredom,
impatience, or other uneasy states. There may be social contexts that are risks for
impulsivity or lashing out at others, such as facing long lines, having tense
discussions with a boss or spouse, or dealing with the typical hassles and
inconveniences of life. Positive feelings and excitement also may trigger
impulsivity such as impetuous online spending because of the “thrill of the hunt”
or marathon gaming sessions. Otherwise enjoyable, upbeat social events may be
risks for ill-chosen comments or dominating conversations. There may be points
in a day when a clientʼs inhibitory skills wane, particularly before prescribed
medications take effect or after they wear off, or any times when a client feels
out of sorts because of hunger, anger, boredom, loneliness, and/or fatigue.
Such situations are high-yield targets for therapeutic homework. Specific
settings can be selected for coping skill practice (e.g., getting in a long line at a
coffee shop to practice distraction strategies such as striking up a conversation or
returning texts). Plans can be developed for managing risky times or transitions
such as mindfulness practice or exercise in the evening when medication effects
wear off. Another valid strategy for handling such risk factors is to avoid them
(e.g., going elsewhere for coffee). Along this line of prevention, self-care is a
useful domain of coping strategies for impulse control, like having a
midafternoon snack to ward off “hangry” (i.e., anger due to hunger) feelings.
At some point, though, clients will face difficult situations because of their
impulsivity, such as a hurtful comment in a fit of anger, getting sidetracked and
forgetting a promise, telling a risqué joke, or having to back out of an obligation
because of overcommitment (see Chapter 4). As with any aspect of self-control,
the relapse rate for impulsivity is 100%—mistakes will be made. Once
recognizing the effect of impulsivity, self-critical thoughts often follow (e.g., “I
messed up again,” “I ruined things,” “I cannot face the person”). These thoughts
interfere with considering ways to undo or at least make amends for an error,
leading to delay and avoidance.
 Clients may minimize the ability to mend such missteps, even after-the-fact,
perhaps because of a sense of diminished social capital and shame. Adults with
ADHD often underestimate the benefit of simply apologizing for impulsive
behaviors. This option is often hindered by guilt, embarrassment, or flipping
responsibility (e.g., “Sheʼs too touchy. Iʼm over it, why isnʼt she?”). In such
delicate situations, the common cognitions elicited are mind reading and fortune
telling (e.g., “My friend will never forgive me,” “My coworker will be angry
that I totally missed our project meeting”) and other self-recriminations.
Nonetheless, these can be addressed with the reframe that good coping involves
facing difficult situations (and discomfort) rather than avoiding them. Creating
an actionable coping plan for the way in which to face such situations is also
helpful.
The discussion of impulsivity drew from previous sections on managing
discomfort and emotions. There is also a creative, motivating aspect of emotions,
which is discussed next.

MANUFACTURING MOTIVATION AND THE VALUATION OF TASKS

Motivation is a term, like the term willpower, that often suggests a fixed
character trait (e.g., “Iʼm not as motivated as everyone else”). When facing
problems from escape–avoidance stemming from the consistent inconsistency of
ADHD, this view of motivation can morph into a belief that the client does not
care, is lazy, and similar attributions voiced by adults with ADHD. These same
adults describe the vexing paradox that “when Iʼm interested in something, I get
a lot done.”
Manufacturing motivation (Ramsay & Rostain, 2015a) is an important skill
for managing adult ADHD, as many priority tasks involve deferred rewards
requiring sustained efforts to achieve. The interventions discussed previously,
chiefly those targeting procrastination, represent coping skills that operate
individually and in concert. Each effort and the sum of these efforts creates an
impetus to engage in a task, helping an adult with ADHD feel “enough” like
starting and eventually crossing the threshold from not doing to doing.
 An aspect of creating motivation is a review of the task valuation. Eliciting a
clientʼs buy-in for a task orients attention to it and informs a corresponding
action plan (e.g., the HYDDT form). The question “Why do you want to bother
doing this at all?” helps elicit a clientʼs motivations that may range from the
aspirational (e.g., “I want to know I can make myself do this”) to the tactical
(e.g., “It just has to be done”). Such valuation has been found to promote
motivated behaviors in nonclinical research (Suri & Gross, 2015). The aim of
valuation is to foster engagement by building up its merits and relevance for a
client, not unlike motivational interviewing (Magill et al., 2018).
As was noted in Chapter 1, motivation is the ability to generate an emotion
about a task in the absence of an immediate consequence (Barkley, 1997). A
personalized review of a clientʼs strengths, passions, and aspirations offer
potential cues and reminders that can foster persistence on tasks. The use of
externalized motivational prompts such as coping cards, inspirational quotes and
images, or other takeaway materials help adults with ADHD recall these values
at the point of performance. For example, a client saving money to buy a car can
hang pictures of makes and models she would like to own or set these as the
wallpaper on her laptop or phone. These cues help keep her goal in mind while
using coping skills to handle spending choices. Such valuation can also focus on
personal attributes (e.g., “I want to know that I can stick to a plan”) and other
objectives apart from the pragmatic goal-focused objective. These sorts of
objectives can also fall within the purview of schema modification, which
modify core beliefs related to self-mistrust (see Chapter 4).
Although focusing on a direct line between intentions and actions, many
objectives include a social and cultural element such as dealing with others or
institutions (e.g., work, school). Therefore, goals may require interacting or
coordinating efforts with others. The next section focuses on an interpersonal
skill for managing ADHD.

ASSERTIVENESS AS AN ADHD COPING STRATEGY: DEFINE YOUR

ROLE
An aspect of wielding social capital is to advocate for oneself, including seeking
help when needed. Such self-advocacy is akin to assertiveness. To reframe
assertiveness in actionable terms, the coping strategy reviewed in this section is
deemed define your role.
Define your role entails identifying a problematic interaction and setting a
plan for handling it to achieve a specific outcome. It serves to organize,
prioritize, and sequence steps to approach it. Step one is to clarify the nature of
the problem, the other person(s) involved in the situation (e.g., boss, teacher),
and the desired outcome, as there may be overlapping but distinct issues. Once
this is established, step two is to define the clientʼs role in this interaction. From
this role definition, step three identifies the specific actions to be performed by
the client to fulfill this role. An important facet in this step is separating out
those factors and actions that are not the clientʼs responsibility (e.g., to convince
the other person about the matter) or are outside of their control (e.g., how the
other person might react).
The clientʼs actions are defined in behavioral terms regarding what steps are
required. These steps include when and how to approach the other person,
including the type of communication (e.g., face-to-face, email), and scripting out
what to say and do in a straightforward, parsimonious way, framed as the
simplest, clearest way to fulfill the clientʼs role in that situation. Step four is
implementing the plan. Once the last syllable has left the clientʼs lips or he or
she has hit send on an email, the client has fulfilled his or her role. Now, it is the
other personʼs role to respond to what the client said. Cognitive interventions
most often address mind reading and fortune telling about what the other person
might be thinking, uncertainty about the outcome, and distress tolerance and
normalization that the client can notice and feel discomfort and still fulfill the
role—and even if a desired outcome is not achieved, the client has still faced the
situation.
Returning to the example of Mitch, the college student with ADHD, he
agreed that it would be helpful to attend his professorʼs office hours for help
after a poor exam grade. However, he was ambivalent, noting discomfort at the
prospect of going to see the professor because of a vague, nonspecific prediction
that it will go poorly. When reviewing this in a CBT session, he agreed that the
professor in her teaching role offers office hours to be of help to students. The
therapist and Mitch defined Mitchʼs student role, which he can fulfill by
physically arriving at the professorʼs office during the appointed hours,
introduce himself, and provide a succinct, scripted summary of his request: “Iʼm
having problems with this weekʼs assignment.” An assertive request can be
reframed as a simple account of the clientʼs view of the facts of a situation. On
uttering the last syllable, he will have fulfilled his student role and started the
meeting.
For most adults with ADHD, defining their role helps to organize and
implement self-advocacy strategies. One of the realities of assertiveness is that
even when used effectively, the desired outcome is not always achieved. This
does not mean that these skills are not useful or that facing the situation was a
mistake. Learning that disappointment can be faced and tolerated is an important
emotional and social skill; in fact, it may promote self-advocacy going forward
by being better able to handle difficulties and setbacks, which is the focus of the
next section.

USING COPING STRATEGIES AND HANDLING SETBACKS

There are no trade secrets for managing ADHD. It is not a problem of not
knowing what to do but instead is a performance problem. In some ways, CBT
for adult ADHD, which requires organization of behavior outside of session, is
like offering an injection treatment for needle-phobia—clients have to do the
very thing that is a problem for them to achieve the outcomes they desire (e.g.,
“If I was able to do those things, I wouldnʼt need to see you!”). This conundrum
and related frustrations inherent in engaging in CBT for adult ADHD can be
considered as among its side effects (Knouse & Ramsay, 2018).
This is the insidious nature of ADHD, as it makes behaviors that others take
for granted more difficult. A food poisoning analogy illustrates how coping
strategies become contaminated by past coping failures. If a person eats a tainted
food, he or she feels ill as the body tries to expel the toxin. The next time that
person is presented with the same food item, the body cannot help but feel
queasy as a protective measure, even if the person is assured the food is fine.
This example helps therapists understand and empathize with the negative
thoughts and beliefs about school, work, or other endeavors that adults with
ADHD are told they should enjoy or value but which are much more
confounding and tedious for them. An avoidant mind-set (and ugh feeling) is a
self-protective reaction to avoid or expel frustration and pain. Adults with
ADHD are already prone to escape–avoidance coping for this reason and the
reflexive conclusion at the first sign of difficulty in CBT may well be “I told you
that these strategies would not work for me.”
Cognitions associated with the basic coping strategies for ADHD cluster
around all-or-nothing thinking (e.g., “Iʼve failed; this doesnʼt work”),
overgeneralization (e.g., “Nothing will work for me”), comparative thinking
(e.g., “Other people donʼt have to work so hard to stay organized”), and
discounting the positive (e.g., “I was almost late”; yes-but thoughts). These
reactions often arise in the early stages of CBT when the focus is on main coping
strategies and tools (e.g., using a daily planner, making a to-do list).
The food poisoning analogy can show that the therapist understands and
concedes that discomfort is part of the change process. A precursor to fostering a
coping mind-set is reviewing a clientʼs history with coping strategies. In many
cases, negative thoughts about coping are based on obstacles with the use of
coping tools and not the utility of the tool itself (e.g., “I lost my planner,” “I did
not check my to-do list,” “I did not enter the meeting in my phone calendar,” “I
got off to a good start last semester but then faded after midterms”).
It is granted that losing tools, using them inconsistently, and establishing
habits are challenging but manageable issues. Socratic questions such as, “If you
locked your keys in your car, would you say that your car did not work?” or “If
someone owns a treadmill but does not use it, would it mean that exercise is not
helpful?” help reinforce the point that not only are these central issues for adults
with ADHD, but that others struggle with them too. Judicious therapist self-
disclosure can reinforce these points and build the alliance (e.g., “Iʼve had this
item on my to-do list for over a week”).
 The therapist can reiterate that ADHD makes it difficult to consistently use
coping tools, though that it can be done. There are some trial-and-error steps
necessary to personalize tools for clients. The experience of many adults with
ADHD is that they were given generic advice about using a daily planner (e.g.,
“Use this planner”) or dealing with procrastination (e.g., “You need to start
earlier”). The CBT model for ADHD sets its sights on exactly how a client does
not use coping skills, which creates customized pivot points for coping.
Clients may search for the right tool, such as a planner or organizational
system, often jumping around to different ones at the first sign of trouble or
simply seeking a new, better one (i.e., neomania; Taleb, 2012). A useful reframe
is that the right tool is one that is good enough and used consistently. Although
smartphones have features that are ideal for many people, others find that they
do not access them enough to be helpful. A client might respond, “I should be
able to use my smartphone as my planner.” This should statement is a stumbling
block when a tool clearly does not work out because, rather than the tool being
the problem and other options explored, it is chalked up as a personal failing.
Embedded in the issue of finding coping tools that are good enough is an
adaptive mind-set that there are diverse ways to cope well. This is an important
notion, from the standpoint of using coping tools, but also finding and fashioning
good fits that optimize well-being and functioning related to life choices and
roles. In some cases, such good fits may challenge implicit outlooks (e.g., “I
should pursue a real major rather than my talent in the arts”; coming to terms
that college or a job is a poor fit).
Rebounding from setbacks is an inescapable part of life and behavior change,
as well as being an essential skill for managing ADHD. Invariable slips ups are
part of the change process. Setbacks are framed in behavioral terms (e.g., “I did
not break down the task into small enough steps” vs. “I procrastinated again”).
The felt experience of increasingly being able to follow through on intentions
provides the raw material for newfound confidence and adaptive beliefs,
including at the schema level, which is discussed next.
CHANGING MALADAPTIVE SCHEMAS/CORE BELIEFS

Schema domains represent an array of categories of normal developmental

needs, such as connection, autonomy, limits/boundaries, and safety/vulnerability
(J. E. Young, 1999). The definitions of schemas and core beliefs are reviewed in
detail in Chapter 3 of this volume. These beliefs operate nonconsciously and are
strongly associated with emotions. Automatic thoughts and other immediately
accessible thoughts can be viewed as a weed with the schema/core belief acting
as the root.
As discussed in Chapter 2, schemas of failure and defectiveness/shame are
among the most frequently endorsed themes in adults with ADHD, and self-
mistrust was proposed as the central schema underlying these schemas. Many
adults with uncomplicated ADHD may not necessarily have problematic
schemas but still struggle with poor self-regulation.
The emergence of recurring themes in cognitive and behavioral patterns
provide clues for likely rules and beliefs. Compensatory strategies within the
CBT case conceptualization reflect efforts to deal with these beliefs that initially
seem adaptive, but which end up strengthening maladaptive beliefs like self-
defeating behaviors. Without a doubt, the most common compensatory strategy
in adult ADHD is disengagement in all its forms (Knouse, Mitchell, Kimbrel, &
Anastopoulos, 2019; Knouse, Zvorsky, & Safren, 2013; Torrente et al., 2014).
As a result, compensatory strategies (viz., disengagement or escape–avoidance)
offer a useful way to identify the influence of latent schemas/core beliefs and to
flesh out the case conceptualization from the inside out.
The Vertical or Downward Arrow (Burns, 1989) is a therapeutic tool for
unveiling schemas/core beliefs. The exercise involves highlighting a recurring
automatic thought and, rather than modifying it, examining it in a specific
manner. The client is invited to perform an exercise of viewing the meaning and
implications of this thought by assuming it is true and accurate. With each
successive response, the question of the meaning of the thought is repeated until
the time at which an underlying, absolute belief is arrived.
For example, a client had difficulties initiating an important work project. He
justified busying himself with other tasks and “getting ready to get ready” for the
project despite knowing the deadline was approaching, which was a common
problem. The client agreed to try a Downward Arrow in therapy where his
therapist asked, “Assuming that it is true that you must do all of these other tasks
before starting the main project, what does that mean for you or say about you?”
The client responded, “It means work is always going to be a struggle for me.
Iʼm not as efficient as my colleagues.” As the therapist continued to probe
successive thoughts, the client provided the following answers: “My boss and
colleagues will see me as an unreliable worker,” “Iʼll probably get fired or have
to quit before I get fired,” “I wonʼt be able to hold down a job,” “I canʼt trust
myself to do what I need to do,” and “Iʼm going to be a failure, unemployed, and
alone because no one will want to be with someone so unreliable.” This exercise
unveiled the maladaptive schemas, and the clinical question turned to what to do
about it?
A benefit of CBT for adult ADHD is its emphasis on promoting adaptive
thoughts, coping skills, and functioning in everyday life, which concurrently
addresses many schema triggers. Directly targeting this level of beliefs and
emotions in adult ADHD requires the use of modified schema-focused
approaches not typically included in extant manuals (Lücke, Lam, Müller, &
Philipsen, 2017; J. E. Young, 1999). These include eliciting maladaptive schema
and core beliefs and developing adaptive or at least modified alternative versions
of them. An important aspect of schema modification is accounting for the
effects of ADHD on the clientʼs experience and self-concept (e.g., “How do you
think you came to hold this belief about yourself?”). It is always useful to
reinforce incremental gains in treatment, as well as to examine how these gains
may support modified outlooks and adaptive beliefs. Checking progress and
identifying how a clientʼs actions contributed to positive outcomes (and catching
thoughts that subtly discount progress, such as attributing it to luck) is a way to
affirm experiences and fashion adaptive beliefs and a sense of efficacy (e.g.,
“How does the fact that you were able to get started and follow through on your
report affect your old belief about yourself?”).
In these ways, CBT can foster a spirit of not only resilience, but also agency
consistent with a growth mind-set (Dweck, 2006/2016). These aims ideally help
adults with ADHD to face and learn from challenges and transcend them through
endeavors clients may not have previously believed were within their capacity to
achieve.

CONCLUSION

The clinical issues addressed in this chapter follow the familiar theme of
promoting engagement and follow-through on necessary tasks and coping skills.
Table 5.2 reviews each of the problems and interventions reviewed in this
chapter. The cognitive domain includes the classic restructuring and framing
strategies for addressing task-demoting thoughts. Cognitive defusion strategies
are helpful with emotion and discomfort management and developing task-
promoting mind-sets of sufficiency, like a client who can accept that he or she is
not in the mood for a task but can still engage with it. These approaches work in
concert in CBT to build experiences with which to modify schemas/core beliefs
and concurrently recognize and develop a clientʼs aptitudes, self-trust, and
overall functioning. Chapter 6 extends these skills to less common, though
important, matters seen in cases of CBT for adult ADHD.

TABLE 5.2. Summary of Cognitive Interventions in Action for Specific Problem Areas for Adults
With ADHD

Common problem area Typical cognitive interventions

Engagement in treatment Psychoeducation

Cognitive modification/reframing expectations
Define pivot points/start small
Procrastination Lessons from procrastivity
How You Donʼt Do Things form
Frame actionable pivot points and tasks
Cognitive modification (e.g., defense attorney)
Cognitive defusion (e.g., accept discomfort)
Emotional labeling/granularity
Implementation plan
Time management Frame/reframe time
difficulties
Sufficiency reframe of effort/energy for task
Defense attorney for negative anticipations
Perspective taking and scaling effort and energy ratings
Disorganization Defense attorney for distorted thoughts about organization skills, including positive
thoughts or rationalizations
Normalize/accept the hassle of using organization strategies
Pair organization maintenance behaviors with positive activities
Emotional management Emotional labeling/granularity
difficulties
Define terms related to strong emotions
Modify/accept thoughts associated with an assumption of lack of control over emotions
Cognitive defusion/acceptance of discomfort
Identify risk factors and personal tells for emotions
Homework practice (mindfulness)
Tolerating discomfort Modify thoughts that one must be in the mood or discomfort free as a precondition for a
task (e.g., front-end perfectionism)
Use discomfort as a signal of the value of a task
Reframe discomfort as a time-limited investment for a valued task
Homework practice
Impulsivity Modify/accept thoughts associated with the assumption that impulsivity is out of
clientʼs control Identify risk factors for impulsivity
Use assertiveness to manage impulsive compliance
Modify/accept self-critical thoughts related to impulsive acts to make amends
Motivation/values Devote time to valuation of tasks
Use external reminders of motivation
Define actionable pivot points to create doable actions to enhance motivation
Assertiveness/self-advocacy Use the define your role technique to clarify the issue to be addressed
Modify distortions associated with mind reading and anticipating outcomes
Recognize underlying assumptions (schemas) that may interfere with self-advocacy
Handling setbacks in skill Normalize setbacks and corresponding discomfort
use
Challenge typical distortions or all-or-nothing thinking, overgeneralization,
comparative thinking, and discounting progress
Personalize coping strategies and identify good fits; challenge “should” statements
Changing negative schemas Identify and use compensatory strategies (avoidance/disengagement) to illustrate
and core beliefs underlying schemas/beliefs
Identify clientʼs incremental progress as evidence for modified schemas/core beliefs
Reinforce clientʼs strengths and coping resources
Use Downward Arrow technique to uncover underlying beliefs

Note. ADHD = attention-deficit/hyperactivity disorder.

KEY CLINICAL POINTS

Even engaging in psychosocial treatment for adult ADHD can be

daunting for clients. There may be grief or anger reactions at the
diagnosis and wondering how life could have been different had it been
identified earlier. Time spent processing these reactions as well as
credible psychoeducation materials and online resources can aid this
process.
Procrastination is arguably the most common presenting complaint
for adults with ADHD. Examining procrastivity, those seeming
productive endeavors used to avoid higher priority tasks, yields
strategies for promoting engagement and follow-through. These and
other interventions, while still focused on behavioral engagement and
follow-through, include important cognitive facets related to task
definition, insufficiency thoughts, and fostering task-promoting mind-
sets.
Time management includes time, effort, and energy management,
how adults with ADHD pace themselves in and across tasks.
Reframing time and perceptions of the effort and energy requirements
of an endeavor, particularly to promote a clientʼs sense of having
enough of these to engage in a task is a key clinical target.
Managing emotions, discomfort, and motivation/values are closely
allied topics. Emotion management includes spotting risk factors and
early signs of negative feelings to take coping steps. Facing discomfort
reactions when facing pivot points and managing the ugh feeling is
arguably the central emotional theme in CBT for adult ADHD.
Mindfulness, acceptance, and cognitive defusion strategies all help
garner a mind-set that “I can feel discomfort and persist on my plan.”
Emotions can be recruited to enhance a value of a task as well as
pinpoint interests that are fulfilling and enjoyable as a component of
self-care and well-being.
Coping strategies for impulsivity challenge the thought that “I
cannot control myself.” Antecedent control is ideal, either taking
preemptive steps to manage or avoid risky situations. After-the-fact
approaches for dealing with the consequences of impulsive actions
require facing discomfort but can mitigate effects.
Assertiveness, including self-advocacy and using social capital, is an
underused coping domain in adult ADHD. Framing interpersonal
situations in actionable terms (e.g., defining your role) keeps with the
theme of outlining actionable plans. Cognitive interventions usually
address thoughts and beliefs about follow-through on these actions.
ADHD is a performance problem, which means that it interferes
with the use of coping strategies. In addition to past frustrations with
using these skills, maladaptive schemas/beliefs can further interfere
with them. Handling setbacks is normalized as an expected occurrence
in CBT for adult ADHD and as a distinct coping skill. Cognitions about
skills or tools that do not work often yield nuanced details that offer
options for coping. Review of relevant schemas also helps illustrate how
these beliefs contribute to avoidance. These beliefs can be reevaluated
and modified as clients make progress, including cultivating a sense of
agency and growth.
6
Additional Clinical Issues in
Cognitive Behavior Therapy for
Adult ADHD

Attention-deficit/hyperactivity disorder (ADHD) is complex because its effects

are so wide ranging, including coexisting clinical issues that have primary or
secondary effects on the core symptoms. This chapter reviews the clinical issues
pertinent to cognitive behavior therapy (CBT) for adult ADHD, as well as some
that may be rare. When rare issues arise, they become clinical priorities, and it is
useful to have a framework for managing them. Topics are presented in the order
of the frequency with which they occur in adults with ADHD. The chapter starts
with the issue of medications, challenges faced by emerging adults, and the most
common comorbid diagnoses for adults with ADHD. This is followed by a
discussion of sleep issues, managing technology use, the effects of ADHD on
relationships, issues faced by senior adults with ADHD, suicidality, and adult
oppositional behavior. The chapter ends with a review of therapist reactions that
may arise in the course of psychosocial treatment with adults with ADHD.

MEDICATIONS
Pharmacotherapy is an evidence-supported treatment for ADHD for all ages.
CBT combined with medications is an effective, often essential regimen for most
adults with ADHD. An argument can be made that anyone diagnosed with
ADHD regardless of age should consider and review medication options for
treatment. The distorted thoughts, like magical thinking and externalizing
responsibility, are some of the most common that arise when adults use
medications to manage ADHD.
Magical thinking is the notion that a medication for ADHD itself will be a
singular, life-changing event, often spurred by accounts in popular books of
awakenings bordering on biblical proportions (e.g., “But this I know: I was
distracted, but now I can focus!”). Indeed, many adults with ADHD find that
effective medical treatment provides a missing piece of a lifelong puzzle and
produces dramatic improvements. These wholly positive accounts make good
reading, but outcomes from medications vary, including among responders.
When clients pin their hopes on medications to totally resolve symptoms and
impairments and unlock their potential, it becomes an issue.
Often fueled by unrealistic hopes, some adults with ADHD engage in
externalizing responsibility and blame their difficulties on medication and, in
some cases, other people. A subset of adults with ADHD endorse patterns of
negativity, oppositional attitudes, and cynicism (Robin, Tzelepis, & Bedway,
2008). It is easy for others, including care providers, to forget or simply not
understand how confounding it can be to live with ADHD. Clients feel frustrated
and powerless to control and direct their own attention and efforts, and they may
hold out hope that medications are the answer. They may then lash out when
these or other hopes are not realized. Relatively common nuances of clinical
practice may be seen as insufferable barriers, including frustrations with the
trial-and-error search for the right medication, dose, and timing; management of
side effects; dealing with the reality of when a clientʼs response to medication
falls short of hopes and expectations; and hassles with insurance and prescription
limits. However, most adults with ADHD internalize their problems.
Pharmacotherapy is supremely helpful and essential for many adults with
ADHD. Psychostimulants for ADHD are amongst the most effective treatments
in clinical psychiatry. However, in many cases there are residual symptoms or
side effects that, though substantially improved, still interfere with functioning
and coping. Dealing with magical thinking focuses on setting realistic
expectations, including the limits of medications (or any other treatment) to be
able to reach or even approach a level of perfectibility.
For most individuals who are disappointed by an incomplete response to
medications, psychoeducation and additional coping strategies are usually
enough to modify outlooks and foster engagement in another treatment or
support service. Young adults with ADHD often struggle with whether to take
medications when facing many developmental stressors and increased
responsibilities, which are made more difficult by ADHD. The next section
focuses on this age cohort and some common issues that may arise in
psychosocial treatment.

EMERGING ADULTS WITH ADHD

Many adults are identified with ADHD later in life because they “got by”
throughout primary and secondary school, perhaps doing well. Mild,
circumscribed symptoms may simmer or be masked during these years,
becoming increasingly problematic but not enough that help is sought. These
undiagnosed individuals face later difficulties in college, when entering the work
force, or at other junctures in life that tax their already impaired self-regulatory
capacities beyond a degree that can be explained away.
Emerging adults (Arnett, 2000) with ADHD often provide retrospective
accounts of getting by in school without completing homework assignments, by
using class notes without doing assigned readings (or vice versa), by relying on
cramming at the last minute, or by outright cheating or excessive parental help
(e.g., finishing assignments or projects for the student). Others sacrifice sleep,
extracurricular activities, and a social life to keep up with the same amount of
work peers complete in less time. Students with ADHD may benefit from
additional support provided by tutors, coaches, and parents sitting with them to
ensure homework is completed and getting them to school every day. Without
these supports, undiagnosed ADHD quickly becomes apparent in college and
work settings in young adulthood.

College Students With ADHD

CBT is well suited for college students with ADHD, as its structured approach
fits well within a semester schedule. The regular demands of class attendance,
and deadline-driven projects provide salient therapy targets. Balancing
academics with a social life, self-care, and other tasks of daily living make
college a veritable executive function (EF) obstacle course. CBT can be readily
adapted to the on-campus needs of students with ADHD (Ramsay & Rostain,
2006, 2016b), including a novel program of group and individual follow-up
sessions (Anastopoulos & King, 2015; Anastopoulos et al., 2018). ADHD
coaching for college students has also produced positive results (Field, Parker,
Sawilowsky, & Rolands, 2013; Parker, Hoffman, Sawilowsky, & Rolands, 2011;
Prevatt & Levrini, 2015).
The core skills for managing ADHD reviewed in Chapters 4 and 5 of this
volume are directly relevant to college students. For example, a friend may
invite a student with ADHD for an evening out the night before a midterm exam.
The most prudent option for the student with ADHD would be to decline the
invitation and study. Using core skills, the student with ADHD can prioritize the
student role (i.e., studying) that night and plan for a night out after the exam,
thoughts and discomfort associated with a fear of missing out or of being left out
can be framed as time-limited and tolerable, and the student can set up a specific
study time and location and a specific starting task, all of which are pivots points
that promote a deferred goal of being ready for the exam.
Writing assignments are at the top of the procrastination list for all college
students (Steel, 2011) but especially for those with ADHD. Writing is a high
cognitive load task that draws on several EF skills. It requires organization and
discipline to schedule and devote time to the task well in advance of a due date.
The mental organization, sequencing, and expression of thoughts and ideas all
make demands on working memory, motivation, and concentration. Students
with ADHD may intend to work on a paper in small increments over time, but
such plans often crumble when facing a writing task, in part because of
reassuring justifications for putting it off (e.g., “I work best the night before a
deadline,” “I need to be in the mood to write”)
The act of writing a paper can be broken down into distinct writing modes.
These modes are designed to address a common frustration for students with
ADHD, as they tend to simultaneously generate and organize ideas in their mind,
type them, and then edit the text into its final form (e.g., perfectionism when
writing). Such perfectionism is likely an attempt to make a first draft be the final
draft to finish the paper all in one sitting. Unfortunately, this can make the
writing process feel bogged down and tedious (e.g., “Iʼve worked on this paper
for an hour, and Iʼm only on the second paragraph”). This type of perfectionism,
as with front-end perfectionism, reflects the desire to minimize discomfort (e.g.,
“If I can finish it in one sitting, then I will be done and wonʼt have to face it
anymore”). Some students who wait until the last-minute use the urgency of a
deadline to override the editing pressure.
Parsing a writing assignment into different writing modes helps to create
more manageable, discrete tasks. Consider the process of furnishing a room,
which requires gathering furniture, having the furniture moved to the room, and
finally, placing the furniture in the desired spots (see Table 6.1). The first writing
mode, the preparatory mode, is like gathering the furniture and other décor
items. This mode includes choosing a topic, completing any background reading,
gathering references, and organizing an outline. A basic first step that serves as
the first smallest engagement step is to review the syllabus about the paper.
Apart from touching the task, this step ensures the student has accurate
information about the deadline, page requirements, and other parameters.

TABLE 6.1. The Furnishing a Room Analogy for Different Writing Modes

Writing
mode Furnishing a room analogy Writing tasks in this mode

Preparatory Collect items for the room Choose a topic, complete background reading, gather references,
mode and draft an outline
Generative Deliver, unload, and place Get thoughts and ideas down on paper, including incomplete
writing items in the middle of the thoughts and placeholder words that will be changed later
mode room
Editing mode Decorate and situate furniture Review and hone what has already been written to make it good
in the room enough to submit

Outlining a paper is a useful strategy often resisted by students who say it

does not work for them. This can be reframed as devoting time to thinking about
what to write or game planning the paper. Thinking of the outline as a
PowerPoint presentation can help students with ADHD put it in more familiar
terms. This makes the task manual as bulleted ideas can be generated and sorted,
which represent ways to externalize and visually sequence ideas. None of these
steps yet have focused on writing the paper, rather they reframe the basic
engagement steps to foster a studentʼs sense of efficacy for writing.
Therapists should watch for signs of pseudoefficiency at this stage (Ramsay &
Rostain, 2015b), which occurs when a student is busy but not productive (i.e.,
procrastivity). A student may collect many more reference materials (e.g., 50
articles) for a paper, when only a few (e.g., five articles) are needed. The student
may feel productive but is misappropriating time, effort, and energy, and now
she faces a large (albeit digital) pile of articles. It may be useful for students with
ADHD to set up a bounded task (e.g., find 10 good-enough articles).
The second writing mode is the generative writing mode, also referred to as
free writing. This mode is like having furniture delivered and unloading it and
other items in the middle of the room. The generative writing mode reflects
getting ideas down on in a Word document, using placeholders for words that
may be replaced with better ones later, and allowing for incomplete ideas,
among other ways to face discomfort.
The final writing mode is the editing mode, which is like situating the
furniture and decorations in the room. Editing text exacts less cognitive load, as
revising existing text is viewed as easier than producing new ideas. If nothing
else, this mode provides an alternative to an all-or-nothing reaction to writing
(e.g., “I canʼt write” vs. “Iʼm in the editing mode”). This option can be used as a
paper starts to take form and a student devotes a writing session to editing. This
target may end up being the sole focus of a writing session or may be an
engagement step that leads to some generative writing.
Students with ADHD may be frustrated by an inability to organize and
express their ideas. One strategy for getting unstuck is to say aloud what they are
struggling to write. Such ideas can be told to a roommate, pet, plant, or simply
by talking aloud to themselves. The switch to verbal expression (vs. typing) and
concurrent auditory processing often help a writer get unstuck. Voice-activated
word processing software is an assistive technology that many students with
ADHD find useful (and is often available at campus learning centers).
For example, a student with ADHD struggled writing papers despite many
insightful ideas. He received excellent class participation marks, but they were
brought down by late submission penalties for his papers. During a CBT session,
the student was urged to describe his ideas for a paper while recording himself
on his smartphone, which would serve as his outline. At his next session, the
student mentioned it was his easiest paper in terms of getting started and seeing
it through, as he was guided by descriptions of his ideas in his own voice.
Bridging strategies are necessary when students must devote separate work
blocks to a paper, stopping and restarting several times. Some helpful tips
include leaving a parenthetical reminder at the stopping point in the document
with the next idea or point to be made. Rereading the last few paragraphs from
the previous writing session is an implementation step (e.g., “If I read the last
two paragraphs I wrote, then I can write at least one paragraph today”).
College degrees have come to be regarded as the minimum criteria for
employability, which has likely contributed to rising levels of student stress
(Hibbs & Rostain, 2019). Most young adults with ADHD at some point will
enter the workplace in some manner, which is the focus of the next section.

Emerging Adults With ADHD at Work

Young adults entering the workforce face challenges related to organization,
time management, and other EFs. Students with ADHD find that college offers
less structure and oversight than high school; there also is less structure and
supervision in day-to-day work life. The goodness-of-fit of job demands and
aptitudes is important for adults with ADHD. Many adults with ADHD report
that jobs that are more hands-on or manual are more protective from the effects
of ADHD (Lasky et al., 2016).
An underappreciated difference for emerging adults transitioning into the
workforce is the different pace. An academic calendar is driven by a semester
framework in which there is a specific start date at which students begin with a
blank slate in terms of grades. Classes, exams, and other obligations are
apportioned over a set number of weeks leading up to a clear endpoint, followed
by a break before the new cycle begins, a bounded (albeit lengthier) task.
For the most part, there is no end of the year in adult life. There are
benchmarks in some jobs (e.g., tax season for accountants; school calendar for
educators), but there is still a steady, unending stream of work to manage. There
also are mounting adult roles and responsibilities outside of work to be handled.
The mechanisms used by young adults with ADHD to get by in school (e.g., all-
nighters) are often no longer feasible in the workplace.
An important coping skill for young adults with ADHD in college or the
workplace is self-advocacy and asking for help. Independent functioning is not
solo functioning; it is the ability to identify and use available resources. By using
the define your role strategy (see Chapter 5), there are many steps that young
adults (and students) with ADHD can take to identify and make use of resources
around them, including eliciting help from others. For college students, available
resources include instructor office hours, accommodations, and campus learning
centers, which provide regular meetings with a learning specialist and access to
voice-to-text software for writing assignments. For young adults in the
workplace, adjusted work hours or written summaries of project of details may
help employees with on-time arrival, keeping track of assigned tasks, or
remembering details. Many of the cognitive and behavioral strategies outlined in
previous chapters and sections can be adapted to managing workplace problems.
The goal for most adults is to move away from their familiesʼ home, however
many young adults continue to live with their families for a time during
emerging adulthood. This can be particularly stressful for young adults with
ADHD and their parents, which may lead to family meetings within the context
of CBT for adult ADHD.

Emerging Adults With ADHD and Their Parents

An issue for therapists working with young adults with ADHD is family
involvement. These emerging adults and their parents face complex, evolving
family dynamics. Parents of young adults with ADHD are straddling the line of
promoting their childʼs individuation with the fact that that child has a relative
delay in self-regulatory skills. These young adults are striving for autonomy
while steering through a phase of life when they assume the mantle of adulthood,
all while dealing with ADHD. There may be disruptions in the process of
becoming an adult (e.g., academic leave, job loss, financial needs) that have
implications for the whole family (Barkley, 2017).
Parents of young adults with ADHD, especially those who are struggling,
may have catastrophic thoughts about their childrenʼs difficulties. Although they
are based on real stressors, these thoughts reflect negative time projections (e.g.,
“He will never start his own life and will live with us forever”). Young adults
with ADHD may have similar fears when facing adulthood: feeling behind
peers, shame at still living at home, or being financially dependent.
When targeting these fears, be it with family members or the young adult
with ADHD, it is helpful to define the difficulties in adult life through the lens of
a growth mind-set (Dweck, 2006/2016) or antifragility (Taleb, 2012), the notion
that facing these challenges can foster strength and progress. Academics fosters
a pass/fail or fixed grade mind-set about performance, whereas the workplace
offers a greater array of performance demands and options. A young adult has
more responsibility and more opportunities for fashioning a good fit in their job
experience, which is particularly relevant for adults with ADHD (Lasky et al.,
2016).
The challenge for parents is to keep their fortune-telling/ruination thoughts
about their adult child in check. This may involve recognizing generational
differences in how young adults approach a job search and job options. The
therapeutic task with young adults with ADHD and their parents is to strike a
balance between allowing the emerging adult to navigate a course through
adulthood and the availability of supports (e.g., housing, finances, treatment; see
Barkley, 2017; Hibbs & Rostain, 2019). Many of the issues facing young adults
with ADHD are addressed in CBT, including helping parents see and support
incremental progress (Knouse & Ramsay, 2018).
The specter of ADHD complicates any aspect of becoming an adult. Adult
ADHD is made more complex by coexisting psychiatric diagnoses, which are
addressed in the next section.

COMORBID ANXIETY, DEPRESSION, AND SUBSTANCE USE

CBT is well-positioned to address the coexisting diagnoses associated with

ADHD, the most common being anxiety, depression, and substance use. These
issues are usually woven into the therapeutic agenda and many coping skills for
ADHD are easily applied to them (e.g., implementation strategies promoting
behavioral activation for depressed mood). All the case-by-case nuances of the
permutations of comorbidities are beyond the scope of this section, so this
overview touches on the most typically encountered cases in the treatment of
adult ADHD.

Anxiety
Anxiety is the most common coexisting diagnosis with adult ADHD. It makes
sense as ADHD makes various tasks difficult for adults with ADHD. Anxiety is
an emotion associated with the perception of uncertainty or risk—the nature of
ADHD itself creates uncertainty.
Anxiety, at least in small portions, is a great motivator. It is an emotional cue
that provides information, meaning, and impetus for either action or inhibition.
Some adults with ADHD, in fact, describe troubles from a lack of such anxiety
(e.g., “My problem is that Iʼm not anxious enough about things. Iʼm
underwhelmed and I just want to be ‘whelmed’”).
 Clinic-referred adults with ADHD often describe a degree of discomfort on
tasks viewed as difficult, tedious, or simply deemed “work,” which triggers
escape–avoidance. At some point, the ratio of avoidance to engagement shifts
such that the anxiety related to facing the task is exceeded by mounting anxiety
of the costs of not meeting a deadline or other consequences. This shift from a
task being an abstraction (e.g., “I know the midterm is coming, but I still have
time”) to becoming an imminent reality (e.g., “The midterm is tomorrow
morning!”) represents a shift in the now/not now conundrum. This shift
transforms anxiety from fueling avoidance to spurring action such as diving
headlong into a task by means of binge working or massed studying at the last
minute (often romanticized as hyperfocus).
From a developmental standpoint, late-identified adults with ADHD often
describe a kindling of anxiety over time as they face increased performance
demands. They may have gotten by in middle school by completing homework
or preparing for tests at the last minute, but they sacrificed quality, grades,
and/or sleep. Anxiety at this age is relatively circumscribed, tied to specific
assignments. As assignments and other duties increase in number and difficulty
in high school, college, and beyond, anticipatory anxiety correspondingly rises
to meet the rising stakes for performance. This results in longer delays in getting
started, with more pressure associated with waiting until the last minute. Binge
working to meet deadlines has greater negative effects on well-being and
performance. At some point, this cycle is no longer tenable, resulting in
escalating apprehension that risks becoming a distinct anxiety disorder.
However, this kindling view of anxiety and ADHD is clinically informed
conjecture.
This anxiety, perhaps better viewed as persistent worry or apprehensiveness,
is tied to the dissonance between knowing what must be done and a mistrust of a
clientʼs ability to do that. It is a visceral aversion to such demands from this
dissonance that manifest as the ugh feelings (see Chapter 5) and worry linked to
tasks, which results in escape–avoidance. This cycle culminates with adults with
ADHD facing the consequences of being late with a task, crafting explanations
or justifications for the tardiness, or rushing to complete it on a wave of stress.
Worry may convert into full-blown anxiety when facing the actual costs of
avoidance (e.g., a failing grade, probationary status at work, relationship
discord).
From an intervention standpoint, this worry is addressed directly by fostering
engagement and following through on matters affecting these life domains using
the coping approaches for adult ADHD, which double as exposure interventions
for anxiety. Cognitive interventions target anticipatory thoughts tied to risk and
uncertainty that fuel avoidance, such as fashioning task-promoting reframes and
engagement plans for facing and following through on tasks, addressing
magnification/minimization distortions, and a clientʼs ability to tolerate
discomfort and uncertainty.
Social anxiety may develop over time. Many adults with ADHD do not view
themselves as shy but describe mounting reticence to contribute in group
settings. This apprehension often stems from inattentive symptoms giving rise to
public embarrassments, like being called on by a teacher during class while in
the middle of a daydream (or conversation with a friend) and having no clue
what has been said. Memories of giggles by others, being chided by the teacher
to “pay attention,” or being present but not taking part in talks with friends, left
them feeling at a loss, “spacey,” or “dumb,” impressions and attributions which
persist into adulthood.
A coping domain for adults with ADHD is the use of interpersonal skills,
which is a form of self-advocacy (see Chapter 5). The simple step of asking
someone to repeat something, admitting to having “zoned out” for a moment, or
admitting to being bad with names are ways to quickly manage social faux pas.
These strategies that could be considered acceptance or shame-attacking for
social anxiety are also workarounds for working memory difficulties (e.g., “Can
you invest 5 seconds of discomfort and ask him to repeat his name?”). Apart
from managing the immediate situation and challenging negative predictions
(e.g., “He will think Iʼm flighty”), these skills improve social collateral by being
self-effacing, staying engaged in interactions, and making better use of support
and connections.
Depression
As with anxiety, the connection of ADHD and depression makes sense. The
impairments associated with ADHD result in failures and lost opportunities as
well as decreased self-esteem, which lead to escape–avoidance. These setbacks
are the direct result of the self-dysregulation characteristic of ADHD.
Depression, an emotion associated with the perception of loss, magnifies and is
magnified by such ADHD-related difficulties.
The overlap of ADHD, depressive symptoms, and negative thinking has long
been conceptualized from clinical anecdote, with growing empirical support (see
Knouse, Zvorsky, & Safren, 2013; Mitchell, Benson, Knouse, Kimbrel, &
Anastopoulos, 2013; Oddo, Knouse, Surman, & Safren, 2018; Serine et al.,
2019). ADHD creates failure experiences, which promote the development of
negative expectations, resulting in cognitive behavioral avoidance, which creates
more failure experiences and a risk for depression.
The implementation-focused approaches adapted to adult ADHD also benefit
mood. Framing actionable steps for engaging in endeavors is consistent with
behavioral activation and graded tasks for mood, as are cognitive interventions
for depressive thoughts. Anecdotally, there is more pessimism about the
anticipated pleasure or other outcome of a plan in cases of depression alone (e.g.,
“Itʼs not worth the bother to go; I wonʼt enjoy the movie anyway”); whereas the
thoughts of adults with ADHD and depression initially emphasize the effects of
disorganization on plans or the effort they require, which then magnify
pessimism about an activity (e.g., “Knowing me, I probably wonʼt even be able
to get ready and get there on time; I probably wouldnʼt enjoy the movie
anyway”). The first facet of this depressive avoidance for adult ADHD can draw
on coping strategies for procrastination, such as specifying the value of a task
and the specific steps necessary to complete it. In terms of the predictions about
enjoyment of a task, scaling a clientʼs anticipated enjoyment (e.g., a 0–100 scale)
and comparing it with the actual experience is a classic approach for dealing
with depressive thinking (Burns, 1989).
In cases of ADHD and depression, reviewing the evidence on which distorted
thoughts are based (e.g., the defense attorney strategy) can be complex. There
will be accounts by adults with ADHD that seem to support a negative
conclusion, such as a college studentʼs saying she will fail a class after failing an
exam. When asked how she arrived at that view, the student will produce a litany
of other missed or failed assignments in the class and point out her current
failing grade. In these cases, the review of the evidence requires closer scrutiny
to determine leverage for change. It may be that the student is recently diagnosed
and has not yet developed coping skills or has not yet adapted them to her
current class. It may be that the class or major (or college itself) is a poor fit or
simply represents a stressful situation to be handled in the process of becoming
an adult. Regardless, options and plans can be formed, even when they are not
ideal (e.g., dropping the class).

Substance Use
Substance use problems, ranging from problematic recreational use to abuse and
dependence, are seen in many cases of adults with ADHD. Nicotine, alcohol,
and marijuana are the most common substances used by adults with ADHD and
there are estimates of a high prevalence of these individuals in substance-use
treatment programs (Nigg, 2013; Notzon et al., 2016; van Emmerik-van
Oortmerssen et al., 2012). Therapists typically encounter problematic use
bordering on abuse, like marijuana or alcohol use that started off as recreational
but has escalated to a point that causes difficulties for clients.
Although there are potential benefits of medical marijuana for some health
conditions (e.g., chronic pain, inflammation, epilepsy), ADHD does not
currently number among them (Volkow, Baler, Compton, & Weiss, 2014). In
fact, early initiation of marijuana use (before 16 years old) is associated with
poor cognitive function, and young adults with ADHD are overrepresented in
this sample (Tamm et al., 2013). Nonetheless, the belief that marijuana and
related products are beneficial for ADHD is a common one encountered by
therapists treating adults with ADHD, particularly young adults (Mitchell,
Sweitzer, Tunno, Kollins, & McClernon, 2016).
 A first step in clinical practice is identifying and raising the issue of substance
use and determining whether clients see it as a problem. Some adults with
ADHD start CBT with substance use as a therapeutic target; for others, there
may be compelling evidence of substance use that affects functioning, including
attempts to self-medicate. Along with motivational interviewing approaches
(Magill et al., 2018), the CBT framework for understanding ADHD is useful. A
collaborative understanding of any use patterns helps to elicit specific pivot
points where a client may be open to change. The Cognitive Model of
Addictions form (A. T. Beck, Wright, Newman, & Liese, 1993) is a useful guide
for breaking down a pattern of substance use into discrete steps and developing
coping strategies at each step.
For example, a client who uses marijuana as a sleep aid reviewed this use
within his broader recreational use. Along with his therapist, the client identified
that he did not like marijuanaʼs amotivational effects on him the next morning.
The client was willing to explore other ways to improve his sleep rather than
using marijuana at the first hint of sleep onset difficulty without committing to
complete abstinence.
An all-or-nothing approach to substance use may result in resistance and risk
for drop out from treatment. Adopting a harm reduction approach is a useful way
to broach substance use. The rationale is framed as making informed decisions
and acknowledging a clientʼs right of self-determination. Defining pivot points
at which to replace substance use with coping strategies makes effective coping
more feasible and less overwhelming and invites clients to experiment with what
works. Therapists can invoke their therapeutic role to point out and confront
obvious difficulties and concerns about glaring substance abuse that requires a
higher level of intervention, including concerns about misuse, abuse, or
diversion of prescribed stimulant medications for ADHD.
As in the previous example, many young adults with ADHD use marijuana as
a sleep aid, as this group is particularly prone to sleep problems, which are
reviewed next.
SLEEP PROBLEMS

Sleep problems result from and contribute to self-regulation difficulties, making

sleep a vital issue for adults with ADHD. There is a wealth of research
documenting ADHD-related sleep issues and their cascading effects on other
regulatory processes, including energy, appetite, concentration and attention, and
impulse control (Barkley, 2015c; Kooij, 2013; Nigg, 2013).
There are cases in which clients have a primary sleep disorder that coexists
with ADHD (e.g., insomnia, sleep apnea, disrupted sleep-onset disorder). Other
sleep problems are described as trouble “turning off” the mind in bed, sleep
delay despite fatigue (e.g., fending off sleep to do one more thing), or simply
being night owls. In some cases of chronic off-time, disrupted sleep patterns, the
shift to a nighttime orientation stems from a progressive behavioral shift in
sleep–wake patterns over time.
Some adults with ADHD report pronounced asleep-to-awake transition
problems, like sleeping through multiple alarms. This state of lowered arousal
and performance during transition is deemed sleep inertia (Tassi & Muzet,
2000). Such difficulty waking in early morning is a defining symptom of
delayed sleep–wake phase disorder and is associated with worse cognitive
functioning on forced morning waking (Solheim et al., 2018).
The thoughts and beliefs that adults with ADHD hold about sleep may
interfere with healthy sleep habits. For example, handling transitions and task-
switching are often problems, including shifting to “sleep mode.” Many adults
with ADHD get mired in tasks (e.g., projects, gaming, flitting from site to site
online) when nearing their targeted sleep time. When probed for their thoughts,
adults with ADHD often report that this is the time they finally do what they put
off during the day, that everyone else is asleep and no one is expected to be
working, and that going to sleep means that they will have to face tomorrow.
Clients with an established history of sleep difficulties often report that they do
not want to lie in bed unable to sleep, choosing instead to keep doing what they
are doing until they cannot stay awake. Sleep itself is sometimes viewed as a
waste of time, with some clients describing “sleep guilt” from having been told
that they sleep away days or nap too much, hinting that undue sleep is a sign of
laziness. This becomes self-defeating as it undermines clientsʼ sleep needs and
interferes with daytime functioning.
A reframe for managing sleep issues for adults with ADHD is that the quality
of a nightʼs sleep starts with the wake-up time that morning. A fixed wake-up
and get-up time (as these are distinct steps) should be set and kept regardless of
the amount or quality of sleep. Once up and going, the reframe is that there will
be enough focus and energy for adequate functioning, even if feeling the effects
of poor sleep, as very often thoughts gravitate to a sense of insufficiency.
Such cognitions about sleep are consistent with subjective–objective sleep
discrepancy (SOSD), the disparity between sleep estimation and
polysomnographic data, that is often seen in insomnia (Crönlein et al., 2019).
This disconnect manifests as recalling less sleep than is documented by objective
data, which can result in the insufficiency view mentioned previously. An open
study (though not specific to ADHD) of CBT for insomnia (Garland, Vargas,
Grandner, & Perlis, 2018) with a psychoeducation component for SOSD was
associated with improvements on a measure of accuracy of sleep estimation and
actual sleep quality (Crönlein et al., 2019). However, conclusions could not be
drawn about whether improved sleep led to better estimations or if there was a
mediational role of psychoeducation.
There are many justifications for staying up late that are enabled by
corresponding justifications for sleeping in the next morning (e.g., “Work
doesnʼt care if Iʼm late,” “I can skip my first class,” “I donʼt have anything to do
tomorrow”). Some clients describe sleep as a boring task. Readying for sleep
requires the hassle of leaving what a client is doing, which presents a barrier to a
healthy sleep schedule.
A cognitive shift toward using a sleep mode behavioral script may include
adaptive thoughts about preconditions for sleep and a clientʼs aversion to plans
(e.g., “I should be able to just go to sleep when I want”). Poor self-monitoring
interferes with tracking clock time, signs of fatigue, and other sleep cues.
Sleepiness is recognized and attended to much later than is healthy, like how
profound thirstiness signals dehydration.
 That said, discrete signs and tells of fatigue can be tagged as cues for sleep.
Apart from physical (e.g., yawning) and behavioral cues (e.g., mindlessly
refreshing a social media page), reminders in the environment can be used.
These prompts may be a designated time (11:00 p.m.), an alarm set for a sleep-
mode script, or a roommate or partner readying for bed.
The sleep-mode script is a useful tool, whether for individuals who have
difficulties quieting their mind or for those who stave off sleep despite being
tired (Ramsay & Rostain, 2015a). This script is a personalized routine of sleep-
promoting steps designed to prime sleep, not unlike a bedtime routine for
children. The script transforms sleep (or at least getting into bed to sleep) into
discrete actions rather than viewing sleep as being wholly out of a clientʼs
control. Steps are personalized and can include logging off and charging devices,
preparing items for the next day, meditation, or reading in bed, to name a few.
Some people have much briefer sleep scripts, noting that once they get in bed,
they quickly fall asleep.
Many adults with ADHD have longer sleep latencies once in bed.
Mindfulness, simple relaxation breathing, and muscle release exercises and an
accepting mind-set that one can be lying awake while still resting are helpful
reframes. Writing out thoughts, to-do items, and worries before getting into bed
is another proactive way to process and externalize disquieting thoughts. Adults
with ADHD can be advised to get up after a certain amount of time and engage
in quiet activities before returning to bed, which is considered a reboot of the
sleep script.
Similarly, many adults with ADHD experience middle-of-the-night
awakenings and have difficulties falling back to sleep. A common automatic
thought in such cases is, “My sleep is ruined, I will not get a full nightʼs sleep,
and tomorrow will be bad.” Psychoeducation provides an adaptive alternative to
this thought. Sleep historians have found that a single, uninterrupted block of
sleep is a relatively recent standard (Johnson, 2014). Accounts from diaries have
uncovered a first and second sleep sandwiched around periods of wakefulness
during which people got out of bed, did light chores, or otherwise quietly passed
time until returning to bed. This can be used to challenge sleep math (e.g., “It is
3:13 a.m., if I fall asleep immediately, I can still get 3 hours and 17 minutes of
sleep”) and suggests that one can be rested enough to keep to their set wake-up
time and adequately face the next day. Blocking the sight of a clock to avoid
sleep math is another useful tip.
Many individuals use their smartphones as their clocks. Concerns have been
raised about the blue lighting used on smartphones and tablets and that they
interfere with the brainʼs sleep-promoting melatonin by mimicking the effects of
sunlight (Wood, Rea, Plitnick, & Figueiro, 2013), though their role as a
distraction from sleep is of greater concern. The next section focuses specifically
on the relevance of managing technology use for adults with ADHD.

TECHNOLOGY

Technology has become ubiquitous in modern life, particularly personal items

such as tablets, smartphones, and smartwatches, which provide unceasing access
to all manner of apps, social media, and information. Voice-controlled personal
digital assistants and smart homes are commonplace. Apart from their many
benefits, these gadgets can easily cross the line where distraction is always just a
click away. Teenagers and young adults with ADHD are among the groups most
disposed to excessive gaming and online activity, including social media
(Guntuku, Ramsay, Merchant, & Ungar, 2019; Li, Zhang, Xiao, & Nie, 2016;
Yen et al., 2017). Most individuals with ADHD, though, simply struggle with
problematic use given that these devices pose an ever-present risk for distraction
and escape.
Adults with ADHD would do well to identify situations in which technology
is a distraction and take preemptive action steps accordingly. A student who
wants to study in the library for an hour between classes can turn off or silence
her phone or otherwise create barriers (stimulus control) to easy access, such as
placing it at the bottom of her bookbag. She may identify and challenge
justifications of wanting to check her phone before studying, instead reminding
herself that she will check and catch up on things after studying (with the need to
dig through her bag serving as a cue for the coping reminder). The use of
implementation plans is also helpful when facing these sorts of temptations,
helping to manage the pivot points between being off task and on task (e.g., “If I
want to check my phone when I get to the library, then I will put it in my bag
right away as I unpack my study materials”).
The previous example is an instance of when studying does not require the
use of technology. However, technology is often essential to a task and poses a
risk for distraction (e.g., using a laptop to post to an online discussion forum for
class). Prospective planning for using technology in such cases can be a helpful
step. This strategy involves setting out a scripted implementation plan for the
task at hand (a targeted cognitive rehearsal), especially for starting a task. This
includes defining realistic, actionable behavioral steps to get started on the task
(e.g., “I will start my class post by going to the library and rereading the
requirements on the syllabus”), setting a realistic task expectation (e.g., “I will
read the most recent posts”), and a realistic, bounded time frame for the task
with start and end times (e.g., “I will work on this for at least 30 minutes—from
1:00 p.m. and will post by 1:30 p.m.—and I will not open up any other windows
until I am done”). Potential task-interfering thoughts can be anticipated, and
adaptive coping reframes and perspectives can be constructed (e.g., “I can
tolerate a delay in checking my email until I finish my work”).
When the use of a computer and online access present risks for distraction,
having a technology use plan helps to make the specific task and plan more
immediately salient. A plan framed as “After I finish my discussion board post, I
will put my laptop on airplane mode to work on my essay for 30 minutes before
I take a break” helps recognize and repurpose a distraction as an incentive. These
plans can be paired with barriers to distraction (e.g., “If I need to check
something online before Iʼm done, I will do so and then put my laptop back in
airplane mode and reread the last paragraph I wrote”).
Accepting and tolerating discomfort and inhibiting the impulse to check
devices are embedded issues when managing technology use. Identifying the
urge to look at a device and responding with a quick appraisal is a useful way to
catch and redirect oneself (e.g., “Iʼd be checking for the sake of checking; I can
wait until after class”), though entering priority situations with an
implementation plan helps reduce getting off track. For adults with ADHD, such
microdistractions open an all-too-inviting avenue for toxic disengagement.
It is fully acknowledged that these strategies are not immutable skills that
guarantee follow-through and safeguard against distractions. Devices provide
undifferentiated signals for new tweets, texts, social media posts, news updates,
and others that constitute a variable ratio reinforcement schedule for checking—
a veritable Skinner box—although clients know the majority of these are
pointless. Yet, adults with ADHD have distinct problems inhibiting such
prepotent responses. Psychoeducation about these behavioral principles helps to
shed light on clientsʼ habitual technology use patterns and existing justifications
and behavioral scripts. This represents yet another area of managing adult
ADHD in which cognitive interventions focus on the notion that “I have no
control over my impulses.”
An aspect of the proneness to distraction through social media, video chat,
texts, and emails and the fear of missing out or being left out mentioned
previously is the desire for social connectivity. Relationships with others is
another domain of life on which ADHD exacts a toll.

RELATIONSHIPS

Managing adult ADHD is made more complicated by how a clientʼs functioning

in adult roles affects others such as spouses/partners, children, friends, work
colleagues, and communities or groups to which he or she belongs. In fact, an
evolutionary view of why and how humans acquired such a sophisticated frontal
cortex and EFs is that it was from the unique demands that arose from group
living and the coevolution of culture and the brain (Barkley, 2012; Henriques,
2011; Sapolsky, 2017). With the advent of these communities, there were
increased selection pressures for cooperation, impulse control, delayed
gratification, and other features of self-regulation required in an increasingly
intricate social world.
The social effects of ADHD have only recently received attention. The core
features of ADHD, as disruptive as they are for clients, are also frustrating for
stakeholders in clientsʼ lives who may experience ripple effects of ADHD
symptoms on joint efforts in which there is an expectation reciprocity,
cooperation, and sharing duties. Therefore, ADHDʼs effect on social capital and
social standing is an important therapeutic element.
The two relationship domains that arise most often in treatment are those with
spouses or committed partners and parents of adults with ADHD. There are
many other potential interpersonal problem areas, but it is dealing with the
romantic and parental bonds that is most likely to result in stakeholders attending
at least one therapy session. Because family meetings were covered in the
emerging adult section above, this section focuses on meetings with spouses or
committed partners of adults with ADHD.
It is common to invite partners into a session of CBT, particularly during the
psychoeducation phase (see Safren, Sprich, Perlman, & Otto, 2017b). Such
sessions provide an opportunity to supply information about ADHD, to correct
misconceptions, and pinpoint strategies that can be helpful. Partners often
provide useful feedback and perspectives on clientsʼ behaviors and areas of
difficulty. It can be helpful to have periodic conjoint sessions to assess progress
and determine any adjustments to be made to the treatment plan. There are many
strategies that can be instituted by the pair together (e.g., a shared calendar
system, task coordination, regular relationship check-ins).
Separate couples therapy is indicated at times, ideally with a therapist
familiar with ADHD. Not yet well researched, there is a study of
psychoeducational groups for ADHD and partners (Hirvikoski, Waaler,
Lindström, Bölte, & Jokinen, 2015) and clinically informed guides for ADHD-
focused relationship therapy (Pera & Robin, 2016).
A complaint voiced by partners of adults with ADHD is that the client does
not care, which is based on frustrations with the effects of ADHD and EF
deficits on duties within the relationship, often leaving partners to overfunction
to manage them. This state may lead partners to assume a parental role, a
dynamic that is the antithesis of a romantic, mutually respectful relationship.
When these issues keep happening, it is seen as a sign that the adult with ADHD
does not respect or value his or her partner. Annoyance may boil over when
facing these matters if the adult with ADHD is (or seems) distracted or otherwise
dismissive of his or her partner, and the adult with ADHD might react with
defensiveness or outright anger. These reactions are fueled by feelings of guilt or
shame about the clientʼs role in the relationship quagmire, not to mention
helplessness at the prospect of his or her ability to rectify it. These problems are
exponentially magnified when partners are coparents or there is any other added
complexity.
It is difficult for partners to fathom the difficulties experienced by adults with
ADHD, much less to not take them personally, which is why psychoeducation is
so important (Kooij et al., 2019; Pera & Robin, 2016). As in individual therapy,
understanding ADHD is the first cognitive reframe for couples insofar as it
provides a shared understanding of the effects of ADHD, reexamines beliefs
about how relationships “should” be, and guides how to adapt a relationship
touched by ADHD. Mutual cognitive modification and defusion skills for
managing and reframing reactions and getting to a solution-focused outlook help
set the stage for better coping and relating for both partners (Ramsay, 2016a). At
the same time, it is essential that the adult with ADHD seek specialized
treatment to develop better coping strategies that will benefit personal and
relationship functioning.
It is important to have daily check-ins to coordinate plans and tasks. This
platform also sets the stage for relationship-enhancing activities and simply
having regular “face time” (the analog version preferred over the digital
version). Collaborative plans for division of labor in the household, automating
bills, and setting up a shared calendar system are helpful for any couple, but
virtually essential when one partner has ADHD. There is a good prospect of an
improved partnership; even working together on these sorts of coping strategies
fosters open communication and intimacy.
The partners of adults with ADHD may wish to seek therapy to address any
relevant personal issues related to the relationship, including as it evolves over
time. A time of life that is of growing interest in terms of ADHD is its effects on
senior adulthood, which is discussed next.
SENIOR ADULTS WITH ADHD

There is an increased interest in ADHD among senior adults, as many of these

individuals, though not previously identified with ADHD, are now seeking
assessments to discern ADHD symptoms from those of normative cognitive
decline (Michielsen et al., 2012). Once a diagnosis is established, many senior
adults wonder if they can change at this age. Although this age group is not well-
represented in outcome studies of CBT for adult ADHD, there is every reason to
expect that they will benefit from it.
Senior adults are defined as individuals who are 60 years old and older,
which creates a near end that could be deemed emerging senior adulthood and a
far end that extends a few decades and beyond. Those at the younger end of this
spectrum include adults who are still in the middle of professional, relationship,
and personal activities with no foreseeable need to change things. However,
matters will likely to crop up that are typical for this period of life, such as
managing work demands (e.g., adjusting to changes in a field of work and
personal coping), relationship and family issues (e.g., caring for spouses with
health problems), plans and goals for semiretirement or retirement, and personal
health.
Planning, organization, and implementation of activities is as much an issue
for senior adults with ADHD as at any other age. Unique to senior adults,
though, is the effect of pending retirement and other roles on the structure of
days and weeks. The prospect of retirement often involves a shift in the number,
types, and ratio of competing demands of work and personal life. The roles of
parenthood change, including adding the title of grandparent, as children are
adults with families of their own. Many senior adults with ADHD describe
having to work harder to keep up with the same responsibilities in their jobs.
This process may be complicated by typical work stressors, such as reduction in
support staff while facing increased performance demands, adjustments to new
procedures and technologies, or the physical demands of certain jobs. With
retirement, there is a loss of the scaffolding of work that may have anchored a
clientʼs schedule inside and outside of work. There may be unexpected stressors
such as an adult child and grandchildren moving in due to divorce, a
spouse/partner or parent with a severe medical condition, or assuming childcare
for grandchildren.
The loss of the work scaffolding is like facing that most difficult grade school
essay on any topic of a studentʼs choosing—there are so many options that it is
hard to select one. The issue with clients can be framed as how they want to
spend themselves. From this plan, which itself can take a while to specify, the
typical coping and implementation strategies for adult ADHD are useful. The
cognitive issues that emerge for this cohort affect follow-through (e.g., self-
doubts, facing the uncertainty of new or different roles and endeavors). Any
doubts are magnified by ADHD as retirement or other new roles involve leaving
a comfort zone and adopting a beginnerʼs mind.
As with adults with ADHD of any age, senior adults with ADHD look to use
coping strategies for managing typical household and administrative tasks. There
may be more time to devote to some tasks (e.g., home improvement projects) or
needed to face new demands (e.g., managing Medicare or retirement benefits).
In some cases, despite having more free time, senior adults with ADHD find it
more difficult to keep up with these matters than when they worked (e.g., “I
know it has to be done, but I donʼt have to do it now”). Retired couples may face
a reorganization of their division of labor and simply the day-to-day
choreography of being around each other in the same physical space when they
would have typically been at work. In some cases, certain duties may suddenly
fall to an adult with ADHD that had previously be handled by a partner who is
now incapacitated or deceased, adding grief and loss to such difficulties
magnified by ADHD.
A thought sometimes voiced by late identified seniors with ADHD relates to
impatience (e.g., “Iʼve waited so long to deal with this; I cannot waste time”).
This urgency can be marshaled as motivation for coping; on the other hand, it
may create frustration when facing typical setbacks. It is important to
acknowledge the realities of the change process, which requires persistence and
patience. There also may be stress with coming to terms with normative age-
linked cognitive changes or medical issues that may affect progress. As with any
client, it is important to examine and affirm incremental improvements to
facilitate follow-through on plans.
Coping strategies for managing adult ADHD, particularly cognitive
interventions, are geared to promote adaptive optimism and hope that things can
be different and better, coupled with strategies designed to promote change.
However, ADHD itself and when coupled with a mood disorder and other
complexities and stressors may lead some adults with ADHD to lose hope,
including considering suicide, which is addressed in the next section.

SUICIDALITY

ADHD is not a diagnosis for which suicide risk leaps to mind as an issue to
consider, unlike depression or bipolar disorder. However, EF deficits across
conditions are a risk factor for suicidality, with clients who attempt suicide
reporting much worse EF deficits than clients who express suicidal ideation
(Saffer & Klonsky, 2017). There is growing evidence that a lifetime history of
ADHD is associated with heightened risk for suicidal ideation, suicide attempts,
and completed suicide when compared with nonclinical control groups
(Barbaresi et al., 2013; Barkley, Murphy, & Fischer, 2008; Salvatore et al.,
2018; Taylor, Boden, & Rucklidge, 2014; Van Eck et al., 2015). The risk for
completed suicide is higher in complicated cases, namely when ADHD, another
psychiatric diagnosis (usually a mood disorder), and substance use coexist.
Another consideration is that adults with moderate to severe ADHD may face
sudden, unexpected life disruptions and distress, such as a relationship breakup,
academic dismissal, or job termination. In many cases, seemingly out-of-the-
blue crises may have been foreshadowed by warning signs that were dismissed
or overlooked; adults with ADHD may also face common unforeseen dilemmas,
such as the death of a loved one, but for which they may be prone to impulsive,
potentially dangerous overreactions.
ADHD is associated with disorganization, impulsivity, emotional dyscontrol,
and poor problem-solving, which are key skills for handling crises and trying to
avoid them. When crises are coupled with failure or shame reactions, there is
risk for suicidal ideation and suicidal acts. Alternatively, some adults with
ADHD experience a gradual erosion of functioning and mounting difficulties
and respond with a slow withdrawal from different facets of life, which leads to
isolation. They may endure a creeping sense of pessimism and hopelessness that
kindles escalating thoughts of suicide over time while losing touch with support
networks.
Regardless of the scenario, focused inquiry about hopelessness and suicidal
ideation (and past attempts) is indicated when adults with ADHD report such
pulling away, as well as when describing circumstances consistent with suicide
risk (e.g., facing a sudden life stressor) if not already reporting suicidal thoughts.
Most clients will respond to this inquiry with an emphatic denial of any
suicidality or cite fleeting thoughts on which they would never act and offer up
deterrents such as children, family, or pets that would prevent them from
following through. It is still useful to periodically reassess for suicidal ideation,
particularly if clients face mounting stressors, mood changes, or other risks (e.g.,
substance use) that could undercut the sway of deterrents in a vulnerable
moment.
A benefit of CBT for adult ADHD is that it targets the very life domains,
roles, and EF deficits from which such life crises emanate, which can address
and reduce these risks. Attention still needs to be paid to risk management,
including eliciting ideation, discussing existing plans and means, and taking
therapeutic steps to promote safety. Coordination with a prescribing physician,
referring for a medication consultation, or other such steps represent good
treatment and risk management. However, there will be cases in which suicidal
ideation is at the forefront of sessions.
Addressing suicidal ideation is another domain in which the therapeutic
alliance is a source of support with which to face and deal with distress.
Cognitive interventions focus on modifying the clientʼs justifications for suicide
and considering such all-or-nothing views considering the finality of death. Such
thoughts and accompanying distress can be acknowledged without acting on
them while taking steps to cope with the immediate situation (accompanied by
specific skills). Perspective taking considers that life stressors do not warrant a
death sentence, and the therapist can draw on examples of individuals who have
faced similar problems and have been able to move through them. The
prolongation afforded by CBT sessions allows for the assessment of suicidal
thoughts, perceived justifications for them, other meanings attributed to
activating stressors, and thinking through the implications of suicide, including
assumptions about what it would accomplish. Laying out these issues, including
emotional labelling, serves to externalize and defuse them, which can promote
coping outlooks and options that foster hope. Active, adaptive coping is another
risk management strategy that builds problem management, emotional
management, and efficacy skills for working through troubles.
In higher risk cases, more frequent sessions, phone check-ins, coordinating
with clientsʼ support systems, consulting with a prescribing physician, and
possible hospitalization in cases of imminent risk are proven strategies, as is
copious documentation of clinical decision making. It also is important to assess
and deal with any specific suicidal plans and means and intent for acting on said
plans. These risks include access to medications in type and amount that could
be used for overdose, access to firearms, or access to any other means.
The risk management steps discussed here are standards for mental health
fields (see Bongar & Sullivan, 2013; Jobes, 2016, for more detailed coverage
and tools). An issue for adults with ADHD is the use of strategies outside the
consulting room. A coping plan is ideally recorded in an externalized format,
which may include relevant suicide hotlines, on-call therapist information,
friends or family to contact for support, and other resources without clients
having to generate them in a crisis. These plans can be kept on mobile devices,
printed and posted at home, or any other means that make them readily available
when they are needed most. Figure 6.1 shows an example of a form used to
externalize coping plans for managing suicide risk.
FIGURE 6.1. Crisis Plan Form for Managing Suicidal Ideation

Emergency Contact Information:

National Suicide Hotline: 1-800-273-TALK (8255) / https://suicidepreventionlifeline.org (online chat

available) / via Twitter @800273TALK

Local Emergency Contact Information:

Clinic/Therapist      Office:
On-call:

Physician/Psychiatrist   Office:
On-call:

Other counselors, professional support:

Nearest hospital/9-1-1:

Support System Contacts:

Family or other relatives:

Friends:

Acquaintances:

Neighbors:

Sponsors, community group, support group, church, etc.:

What are steps I can take to keep myself safe right now? (e.g., let someone hold my pills)

What are my deterrents for ending my life? (e.g., family, children, pets, knowing I will feel better)

Reasons for living:

Emotional management steps I can take right now: (e.g., What has helped in the past?)
 Specific coping strategies I can use right now: (e.g., What has helped in the past?)

Steps I can take to manage problems and make things better:

Hopeful plans for living and for the future:

Risk management strategies help to deal with suicidal ideation once it is

activated. Preventing and handling problems before they become crises is
preferred. A strong therapeutic alliance is very helpful for handling such
difficulties. The next section addresses challenges to this alliance, namely,
oppositional behaviors by clients.

MANAGING OPPOSITIONAL BEHAVIOR

Oppositional defiant disorder commonly coexists with ADHD in children and

teenagers. Emotional dyscontrol is proposed as the thread connecting these
diagnoses, as children and teenagers with poor emotional control coupled with
settings without sufficient checks and balances on behavior can result in an
escalation of acting out behaviors (Barkley, 2015b). Although not typically
identified as such, oppositionality can persist into adulthood, causing rifts with
treatment providers, educators, and other helping professionals. At the very least,
there may be cases of externalization of blame in situations that can be trying for
significant others and providers.
There is often truth in the frustrations voiced by adults with ADHD. There
are reasonable adjustments or accommodations for task expectations at work or
school, or in-home matters that can ease the burden of clients in these settings.
Even in such circumstances, the way adults with ADHD react to typical stressors
and apparent slights is what creates conflict and hard feelings, such as
negativistic, angry reactions (Robin et al., 2008).
For example, during a CBT session, a college student with ADHD voiced
anger about a professor who refused to grant him a second extension on an
assignment. The student said the professor still expected him to submit the
overdue assignment along with other items due earlier in the semester; the
student was furious that the professor refused to “let them slide.” The therapist
was soon included as a player in the scenario—“And I cannot believe that you
will not write a letter to the dean about how this professor is undermining my
ADHD treatment by not granting me these reasonable accommodations!”
Such delicate clinical matters require tending to the alliance, counterbalanced
by the fact that this alliance must continue to be therapeutic. In the previous
example, the therapist defined his role and managed discomfort to recount the
series of facts as stated by the student. This summary included facts not
mentioned by the student, like how the professor offered to meet with the student
outside office hours to provide extra help and how the professor had already
adjusted assignment requirements in addition the extension on the current
project. The therapist reiterated that CBT is designed to support coping, such as
facing, handling, and learning from natural consequences but not necessarily
engineering them. The therapist suggested that they strategize a plan for
handling the overdue project. As the student pressed for a letter to the dean, the
therapist outlined the types of documentation that he considered within his role
to provide (e.g., updates for the student disability office). The purpose was to
clarify the limits for handling the current quandary and create a spirit that the
therapist and the student could disagree and still work together to manage the
predicament.
At a subsequent session, the scenario was reviewed to understand the
studentʼs expectations for this extra level of alteration of assignments (already
having secured formal academic accommodations). The student said that he had
been accustomed to getting what he viewed as reasonable, on-the-fly
adjustments to schoolwork of the sort he received in high school. He felt
overwhelmed by the view that he was left to fend for himself alone while facing
mounting work. This grasping of past overaccommodation was leveraged to
frame and promote the need for better self-advocacy skills and the use of
existing coping resources and strategies for assignments. These insights also
helped the therapist better conceptualize and align with the studentʼs emotions
and vulnerability and anticipate bumps in the road the student might face. It was
a tense but ultimately important few sessions that became a turning point for the
student and how he managed college.
Self-advocacy can be overwhelming and frightening. As was noted above, the
frustrations of managing ADHD may come out in CBT sessions and be directed
at therapists. Therapy offers a supportive, safe place to address such issues, but
therapists are people too, and they must monitor their reactions to clients, which
is the focus of the next section.

THERAPIST REACTIONS/MISCONCEPTIONS

A benefit of the therapeutic relationship in CBT is that clients work with

therapists who are versed in the nature of ADHD. However, therapists and other
helping professionals and educators are prone to any and all forms of distorted
thoughts when working with adults with ADHD.
CBT sessions provide a natural laboratory for testing out thoughts from
clients (e.g., “You must be sick of the fact that Iʼm still struggling with
procrastination after a month of CBT”). After exploring any assumptions by the
client, a therapist might reframe the thought (e.g., “Procrastination is tough to
manage and is a good use of session time; Iʼm glad that you are willing to focus
on it”). This sort of judicious self-disclosure (M. S. Barrett & Berman, 2001) can
be helpful to address issues like comparative thinking (e.g., “You said that no
one else seems to need a to-do list—hereʼs mine”). Some clients respond with
surprise to this notion, but it may prompt reactions such as “But you probably
get things done—I still donʼt,” which becomes a therapeutic item.
On the other hand, therapists will have reactions to apparent lack of progress,
attendance or timeliness issues, and various other realities of treating adult
ADHD. Therapists will have to self-assess whether reactions reflect their own
countertransference or beliefs about themselves that must be managed, such as
unrelenting standards for helping people change (e.g., “Sheʼs right, we have
been spending a lot of time on procrastination; Iʼm a so-called ADHD expert but
Iʼm not helping her”). At the same time, it can be useful to assess whether a
change in approach is warranted (e.g., “I thought about what you said about our
time spent on procrastination, and I want to check with you and ask if there is
something else going on for you that I might be missing”). Such nondefensive
reactions can be used to aid treatment.
Therapistsʼ reactions can be understood as how others are likely to react. This
understanding can be used to promote empathy, review of the case
conceptualization, and identifying compensatory strategies such as excessive
apology for lateness (e.g., “Iʼm so sorry that Iʼm late again; I understand if you
no longer want me as a patient”) or externalization (e.g., “Why canʼt I have a full
hour? Youʼre supposed to help me be on time”). In either case, the issue helps
therapists get it in terms of the mind-sets of adults with ADHD and their
influences to better support their ongoing therapeutic efforts.
Therapists are normalizing for clients that ADHD requires ongoing efforts to
manage it. This reminder is apropos for therapists too, as they continue to
partner with adults with ADHD on this worthwhile and meaningful undertaking
of CBT for adult ADHD.

CONCLUSION

This chapter focused on less common but relevant clinical issues for therapists
working with adults with ADHD. These issues run the gamut from suicidality
and comorbidities to issues inherent in different phases of adult life to managing
sleep, technology, and relationships. For the most part, interventions focus on
navigating pivot points and fostering engagement and reducing escape.
Nonetheless, the cognitive domain of CBT was emphasized to promote clientsʼ
belief in the ability to implement plans, get the most out of various forms of
treatment, and develop self-regulatory efficacy for follow-through on various
coping skills and life endeavors.
KEY CLINICAL POINTS

Although medications are highly effective in treating symptoms of

ADHD, adults with ADHD may hold some unrealistic expectations
for these benefits or how much providers will be able to help,
underestimating the need for additional treatments and coping
skills.
Emerging adults are launching into new roles in academics and in
workplaces, in addition to assuming other responsibilities. While
doing so, they are navigating the need for support from family with the
desire for increased independence, which often creates family stress.
Existing coping strategies for adult ADHD can be modified to
navigating this phase of life, including sessions addressing family issues
for parents and their adult children.
CBT is well positioned to manage the most common coexisting
factors in adult ADHD, namely anxiety, depression, and substance
use problems. Interventions for fostering engagement can easily be
adapted to exposure-based and behavioral activation strategies for
anxiety and depression, respectively. A harm reduction approach for
substance use can identify problems for which clients are self-
medicating or otherwise are motivated to change.
Sleep is a problem area for many adults with ADHD for a variety of
reasons. Very often a manifestation of self-regulatory difficulties is a
problem transitioning to sleep mode. Adults with ADHD often report
difficulties winding down and turning off their minds in addition to
delaying sleep. Creating a sleep script for the transition to sleep mode
can be helpful.
Managing technology is an important topic for adults with ADHD.
Identifying settings in which technology use is particularly problematic
(e.g., studying or other priority tasks) helps to craft specific coping and
implementation plans. Stimulus control (e.g., putting an item on
airplane mode or in a book bag) can help reduce distraction.
The effects of ADHD on various relationships and social bonds has
only recently received attention. Parents of emerging adults often
provide useful information during the evaluation phase. They may be
involved in treatment of their adult children during college and
particularly afterward if the young adult still lives at home. Similarly,
spouses and committed partners witness and can provide information
about the functioning of partners with ADHD. As part of CBT for adult
ADHD, partners may attend periodic sessions to provide insights and to
gain an understanding of the effects of ADHD to make sense of it and
their reactions. There are some useful coping strategies couples can use
(e.g., daily check-in) but specialized couples therapy may be needed.
Senior adults with ADHD face unique coping issues at this stage of
life. Those at the younger end of this spectrum are still in their careers
but face an increase in typical life stressors associated with aging and
family matters. With retirement and beyond, there is a loss of the
structure provided by work and a need to redefine plans, which includes
implementing the steps to pursue new endeavors and goals while
dealing with life changes.
A lifetime diagnosis of ADHD is associated with elevated risk for
suicidal ideation and attempts, particularly in complex cases. Adults
with ADHD may experience precipitous setbacks (e.g., job loss;
academic suspension). A thorough risk assessment, including
management plans, is good practice, as is consultation with other
providers and family members.
The therapeutic alliance is an essential facet of CBT for adult
ADHD. A strong alliance provides a foundation for conceptualizing and
responding to oppositional behaviors and negativity outside and inside
the therapy room. Therapists reactions may have to do with self-doubts
about whether the therapist is being helpful or frustrations with
behaviors common to adult ADHD (e.g., lateness). These cognitions can
provide useful information that help inform and strengthen the case
conceptualization and treatment for the benefit of clients.
7
Case Examples

This chapter presents extended case examples to illustrate how cognitive

interventions fit within a course of cognitive behavior therapy (CBT) for adults
with attention-deficit/hyperactivity disorder (ADHD). All identifying
information has been changed to protect privacy and confidentiality; the case
examples presented here are drawn from actual clinical encounters but represent
a hybrid of cases for illustrative purposes. All clients underwent a thorough
diagnostic evaluation for ADHD. Therapist commentary is provided throughout
the description of the cases.

GRACE-ANN

Grace-Ann is a 42-year-old married mother of two, who sought CBT due to

recently having been placed on a performance improvement plan at work. She
works in an administrative support position within a large health care
organization. She had previously worked part-time for a local medical practice
but sought a full-time position once her children entered middle school.
Grace-Ann anticipated that she would struggle with the shift to a faster-paced
position, but after 2 years her disappointing performance reviews could not be
blamed on an adjustment issue. She had been diagnosed with ADHD in college
after being placed on a 1-year academic leave. Although needing three extra
semesters, she graduated college with a combination of a prescribed stimulant
and regular meetings at the campus learning center. Grace-Ann still takes
medication, which helps, but the problems in her current job have escalated to
the point that she is concerned about potential dismissal.
Grace-Ann identified her primary goal for CBT as better organization and
follow-through with tasks at work. When asked for a specific example of this,
she cited a current delay on her supervisorʼs request for patient-visit data. She
said that her boss requested it days ago, but she had not yet acted or even
responded despite knowing it is a priority.
THERAPIST:  Would it be fair to say that this is a relatively common
example of the type of issue that you want to improve?
GRACE-ANN: Yes. Today itʼs the visit data, but I seem to put off tasks like
this all the time when I know full well it doesnʼt make sense.
THERAPIST:  We can use this as an example of how you can break down this
sort of task and figure out how you do not do things to set the
stage for better follow-through on this and other tasks. Would
that be a good use of our time today?
GRACE-ANN: Yes. This is exactly what I need help with.

THERAPIST COMMENTARY: This is an example of starting small

with a relevant problem that is likely representative of larger, more
pervasive issues. In addition to clarification of broader therapy goals, this
issue provides an opportunity to socialize Grace-Ann to the CBT approach
using the structure of the How You Donʼt Do Things [HYDDT] form,
including its cognitive elements [see Chapter 5, this volume]. This form
and task also are a good initial homework task.

THERAPIST:  First, what is your overarching goal for wanting to handle this
task in a timelier manner? Why is this of value to you?
GRACE-ANN: Right now, I want to survive my next performance review and
keep my job. But it would be nice to get things done and not
have the stress of them hanging over my head. I want to know
that I can rely on myself to do these things simply because I
need to do them.
THERAPIST:  Those are some good reasons. So, youʼre saying that follow-
through on this and similar tasks would reflect well on your
job performance and help you to feel less stressed and more
confident in yourself, in general. Focusing on this project,
what exactly do you have to do?
GRACE-ANN: There is a sorting feature in the electronic medical records
system that allows me to organize and analyze data to give my
boss.
THERAPIST:  Even before getting to the sorting feature, what would be the
smallest first step that you would need to take to get started, to
actually “touch” the task?
GRACE-ANN: What do you mean?
THERAPIST:  Are there steps you must do on the computer before even
getting to the sorting step?
GRACE-ANN: I need to get the department identification numbers before I
run the sorting features. It is only a couple of steps to make
sure I have the right numbers.
THERAPIST:  Okay, even though it is a small step, it is one to factor into
your planning. On an even more basic level, though, when you
walk into the office, what would have to do to even get access
to these department numbers and patient data? If you were
scripting this out in a series of instructions for a robot, what
would the robot have to do once it entered the office doors?
GRACE-ANN: Well, the very first thing Iʼd have to do is go to my desk and
 log on to the computer.
THERAPIST:  Once logged on, what is the next step directly related to the
project?
GRACE-ANN: There is a drop-down menu for analytics which is what I use
for data sorting. There is another drop-down menu that I can
use to find the department numbers I need for the data search.
THERAPIST:  Okay. What we are doing here in terms of a portable skill is
one that we all know—break down a task into small steps.
This sort of scripting helps lay out a sequence of steps like a
recipe. Despite knowing this, it is the doing, the
implementation where problems arise for most people.
GRACE-ANN: I know, I beat myself up at the end of each day when I look
back at all the times when I could have taken care of this. It
sounds so simple sitting here talking about it.
THERAPIST:  This is a challenge for anyone with a human brain, but even
more so when dealing with ADHD. By simply taking some
time, as we are doing here, to lay out some actionable steps
you can increase the likelihood you will start and follow
through. There are a few more details that can help increase
the odds. When will you do this? What is a specific day and
time that you can commit to devoting to this task, an
appointment for doing it?

THERAPIST COMMENTARY: This guided discussion provides Grace-

Ann with a framework for understanding her procrastination and
corresponding high-yield pivot points for engagement, which is the goal of
the HYDDT form. This process reflects the prolongation of these moments
and the personalization of strategies for better navigating them.
GRACE-ANN: I can do it first thing tomorrow morning when I arrive at the
office.
THERAPIST:  Specificity helps with follow-through because it gives an exact
target. What time tomorrow?
GRACE-ANN: I get there at 8:30 a.m.
THERAPIST:  Let me play devilʼs advocate—is that a realistic plan? It sounds
feasible now but are there other things that might get in the
way of this plan at 8:30 a.m. tomorrow?
GRACE-ANN: Well, I typically spend time taking care of pressing emails and
simply settling in. Iʼm usually not up and running on things
right at 8:30 a.m. I guess 9:00 a.m. is probably more realistic.
THERAPIST:  Okay, 9:00 a.m. tomorrow morning. How long do you think it
will take to sort through the data and be ready to give it to
your boss? Can it be done in one sitting or will you need more
time?
GRACE-ANN: It really should only take about 30 or 45 minutes, though
sometimes these things take longer than expected because of
missing data or other issues that come up.
THERAPIST:  Focusing on tomorrow at 9:00 a.m., what is a realistic
expectation for a minimum amount of time you can devote to
this task, even if you encounter difficulties?
GRACE-ANN: Iʼd say 45 minutes should be more than adequate.
THERAPIST:  Again, at 9:00 a.m. tomorrow will the prospect of working on
this task until 9:45 a.m. look realistic? Would it be better to
start with 30 minutes?
GRACE-ANN: I have a 10:00 a.m. meeting that includes my boss, so 45
minutes is realistic and gives me time to prepare for the
meeting. It would be nice to tell her Iʼm done or at least update
 her.
THERAPIST:  That sounds good. So, the plan is to start on the task at 9:00
a.m. tomorrow by logging on to your computer, accessing the
drop-down menus, and working on the data until 9:45 a.m.
GRACE-ANN: Yes, that sounds good.
THERAPIST:  Where will you do this?
GRACE-ANN: My desk.
THERAPIST:  Iʼm going to again raise the question of whether this is the best
place for this task because I would guess there are a lot of
distractions and people looking for you.
GRACE-ANN: There are, but I should be able to make myself do it there. Itʼs
my desk.

THERAPIST COMMENTARY: Grace-Annʼs use of a should statement

in this case is an opportunity to shed light on the role of cognitions at
various pivot points. This relatively innocuous should thought is an
example of the influence of such thoughts for adults with ADHD in terms
of choices that affect pivot points and moving from being off task to being
on task.

THERAPIST:  Fair point. Though, let me propose that even though you
should be able to work at your desk, are there better options
for limiting distractions, even as a back-up? This is one of the
ways automatic thoughts, this one being a should statement,
can arise and even subtly limit options.
GRACE-ANN: Well, people do stop by my desk and ask me for things,
especially in the morning. There is a floating office with a
desk and computer that I can use. I can close the door and hide
 out there.
THERAPIST:  For this plan tomorrow, which do you think is the better
option, desk or floating office?
GRACE-ANN: Iʼll give the floating office a try.
THERAPIST:  So, at 9:00 a.m. tomorrow the first step of the plan is to go to
the floating office, close the door, sit at the desk, log on to the
computer, and click on the analytics tab.
GRACE-ANN: Yes.
THERAPIST:  And the stop time of 9:45 a.m. still seems realistic? It gives
you time before the meeting?
GRACE-ANN: Yes.
THERAPIST:  With this plan in place, letʼs consider the barriers to follow-
through. At 8:59 a.m. tomorrow, what could go through your
mind, what thoughts might you have that would interfere with
it?

THERAPIST COMMENTARY: Introduction of task-demoting thoughts

using the HYDDT.

GRACE-ANN: I know myself, and it sounds good now, but when it comes
time to work on it, I wonʼt feel like doing it and I might put it
off and take care of other details.
THERAPIST:  That is a great example. You have a very good action plan, but
we are trying to ensure that your carry it out, itʼs all about the
implementation. What other tasks will seem more important
than the data sorting and how will you handle this impulse to
keep to the plan?
GRACE-ANN: Iʼm not sure. These other tasks eventually must be done, too.
THERAPIST:  Yes, thatʼs true. But how do you stick up for the importance of
the data sorting? Another way to think about it is viewing
justifications for putting off the data sorting as a thought or
case against your plan made by a prosecuting attorney in
court: “Your Honor, Grace-Ann should not work on the data
task right now. She can accomplish many other tasks in those
45 minutes.” While there is some truth to this argument, it
leaves out important information. This is the nature of the
automatic thoughts we discussed in our first meeting. These
thoughts are the case made by the prosecutor and the judge
renders a decision not because the case is strong, but because
only one side is argued. The cognitive element, the C in CBT,
focuses on examining these thoughts and their effects on us
and our options for handling things, which is like the role of a
defense attorney on our side, but still bound by the evidence.
Does this make sense?
GRACE-ANN: Yes, I like that example.
THERAPIST:  So, how would your defense attorney respond to the
prosecutorʼs claim that the small tasks you will likely
encounter tomorrow should be done first?
GRACE-ANN: The data sorting is the priority. I only need to work on it for 45
minutes, and then I can update my boss, which is more
important for my performance review. Iʼll do the other tasks
later.
THERAPIST:  Nice. I like the view that the task is only 45 minutes, which is
why we try to specify bounded work blocks so that it is more
manageable. To keep perspective, are there other things that
you do for “only” 45 minutes that can remind you that it is a
manageable length of time?
 THERAPIST COMMENTARY: The various names of the coping
strategies are used as part of the socialization to CBT for adult ADHD but
also to personalize it. Such names serve as hooks and reframes that
increase the likelihood that clients will remember and use skills, such as
defense attorney, bounded task, and others. Grace-Annʼs use of “only 45
minutes” can be recruited as such.

GRACE-ANN: What do you mean?

THERAPIST:  Thoughts about time required of a task affect our belief of our
ability to carry it out. For example, if someone must do
something for 5 minutes, we will reframe it as 300 seconds,
which sounds more manageable and increases the likelihood
of follow-through.
GRACE-ANN: My train ride to work is about 45 minutes and is not that bad. I
can think about the data sorting as the length of the train ride I
do every day. If nothing else, I know Iʼll be done at 9:45 a.m.
THERAPIST:  Those are good ones. What about the thought that you wonʼt
feel like doing the task?
GRACE-ANN: Thatʼs tougher. I worry a lot about not doing a good job or my
boss pointing out something Iʼve missed, particularly now
with being placed on probation.
THERAPIST:  So, when facing the plan tomorrow morning you might have
thoughts of uncertainty that you might not do a good job and
might miss something, made worse by the performance plan.
GRACE-ANN: Yes, and these things have happened before to me. Even when
I think Iʼve done a good job, I canʼt fully trust my work. It can
make it hard to even start.
THERAPIST:  Then it makes sense that part of you may not feel in the mood
 for the project, but this increases the likelihood of escape to
easier tasks. Is there a mind-set to help you get started? Have
you had experiences facing other challenges that might be
helpful in this case?
GRACE-ANN: Well, if my boss keeps asking for the data, this will not help
my standing with her. I can at least get to the point at which I
run the analyses. I almost did not apply for this job in the first
place, but I figured I had nothing to lose. I can do the same
here and take my best shot.
THERAPIST:  Nice. In effect what I hear you saying is that you do not yet
know if you will have problems, so go ahead, face it, and trust
the plan. How can you use these reminders tomorrow?

THERAPIST COMMENTARY: This section highlights the

externalization of information, motivation, and coping plans to increase
their use at the point of performance.

GRACE-ANN: Iʼm going to put a note in my planner right now to remind me.

THERAPIST:  While youʼre doing that, Iʼd suggest making a task
appointment in your planner for the 9:00 a.m. to 9:45 a.m.
time. Recording plans and referring to them in a planner or
elsewhere are prompts for engagement and follow-through.
You mentioned that you might not feel like working on the
sorting data project. How do you experience those sorts of
feelings?
GRACE-ANN: I donʼt have panic attacks or anything, but I get a sinking
feeling when Iʼm given a project and itʼs like, ugh, even for
basic ones. Once I get started, though, it usually goes okay.
THERAPIST:  That last part is a good defense attorney thought for managing
 your emotional reaction, the fact that once started, these
feelings improve. Based on your past and recent frustrations,
this not-in-the-mood reaction makes sense. You used a word
that Iʼve heard used to describe discomfort about tasks, the
ugh feeling. How might you handle your ugh tomorrow?
GRACE-ANN: Yes! Ugh is a good description! I know that once I start, it is
not that bad and it will feel good to get it done but it is like I
feel . . . ugh, just not wanting to do it.
THERAPIST:  How long does it take to get to that point at which it is not so
bad? Do you think you will be tense and uncomfortable the
whole 45 minutes tomorrow or not that long?
GRACE-ANN: No, no, no, maybe a couple of minutes, if that. In fact, some
days I feel stressed on the way to the office but by the time I
get to my desk, Iʼm fine.
THERAPIST:  Thatʼs a good reminder that facing discomfort is a good way to
relieve it. In fact, it sounds as though the tension you describe
some mornings before work gets relieved by facing it with
your get-to-work plan or script.
GRACE-ANN: I never thought of it that way.
THERAPIST:  Yes, exactly, that is what we are doing here—defining the data
task in actionable, doable steps. Many clients learn that they
can face a task while feeling discomfort and having negative
thoughts, noticing them, rather than expecting to be
discomfort-free. Any other reminders that might be helpful for
managing the gut feelings?
GRACE-ANN: I think the idea that Iʼll feel better getting something done on it
will be helpful.
THERAPIST:  That is important—we underestimate the positive feeling of
getting things done, even by getting started, through
 discomfort, and making headway. All this being said, what are
some escape behaviors that you might anticipate—things that
would signal that you got off task?
GRACE-ANN: As I mentioned, checking emails, returning phone calls or
texts, or answering questions.
THERAPIST:  These are signs that you are avoiding the task. What is a good
reminder to help increase the likelihood you will get started on
your plan?
GRACE-ANN: There is nothing that will be so important that it cannot wait
until 9:45. I can put my phone in a pocket or in my purse. Iʼm
feeling confident Iʼll get started.
THERAPIST:  What about other people seeking you out for help?
GRACE-ANN: I just need to get to the other room and close the door. If I can
do that, I can get started.
THERAPIST:  So, if you go to that room and close the door, then you can log
on to the computer and start.
GRACE-ANN: Yes.
THERAPIST:  This sort of if-then statement is called an implementation
intention strategy. It is part of an interesting line of research on
turning intentions into actions. We boil down a goal or a
difficulty with that goal into an if-X-then-Y reminder for a
specific coping plan. What about recording your if-then
reminder in your planner?
GRACE-ANN: Let me get it down now: “If I go to the floating office, then I
can log on and start.”
After running through the scenario for her data entry, the therapist recorded
the planned strategies on the HYDDT form and gave it to Grace-Ann as a
reminder and a tool for facing the data task the next day. It also provided a
template that Grace-Ann later used to good effect in other situations, including
work, home, and personal endeavors.
Grace-Ann completed the data-sorting task as planned and over the next
sessions made progress on the timelier performance of work duties, with some
ups and downs. The ups were used to point out her skills and gains; the downs
were used to focus on and hone coping skills (e.g., her planner as a tool) and
interpersonal skills for self-advocacy and the clarification of details and
expectations with her boss.
A cognitive theme across domains was Grace-Annʼs assumption that she let
down others. First and foremost was her concern about meeting expectations at
work, per her probationary status at work. At various times, though, she worried
that her poor follow-through was a letdown to her family. This issue came to a
head in an unexpectedly emotional session.
GRACE-ANN: It might seem silly, but I want to talk about Halloween today.
THERAPIST:  Thatʼs right, itʼs today. Whatʼs going on?
GRACE-ANN: I need to stay late at work today because we process billing
and other matters at the end of the month. As of now, Iʼll get
home just in time to take my kids trick-or-treating. But I
havenʼt gotten candy yet to give out to trick-or-treaters who
come to our door, not to mention having no time to give my
kids dinner before they go out.
At this point, Grace-Ann becomes genuinely upset and tearful.
THERAPIST:  This is obviously important for you, Grace-Ann. Iʼm glad you
chose to share this. Take your time, when youʼre ready, let me
know whatʼs going on for you right now.
GRACE-ANN: (Sniffing back tears) This is stupid for me to take up therapy
time with this, but I should have taken care of the candy before
now. I canʼt believe I waited until today. I need to go to work
right after the session, so I canʼt get the candy now. Even if I
 stop by the store on my way home, thereʼs only going to be
crap candy left. Iʼll be one of “those people” who wait until
the last minute. Then Iʼll be late and make the kids wait for
me, or Iʼll have to catch up with them and explain what
happened in front of their friends and other parents. Iʼm sure
[my husband] Jim will give me that disappointed, not-again
look. Iʼm sorry to be unloading all of this in here. I must be
your most messed-up client.

THERAPIST COMMENTARY: There are a host of thoughts and

assumptions voiced by Grace-Ann, but this sort of situation reflects the
benefit of a case conceptualization. The strong emotions and theme of
disappointing others suggests schema-activation. This emotional moment
and related meanings of it were explored in detail after empathically
witnessing Grace-Annʼs account of the full picture. Where needed, the
therapist clarified various statements (or thoughts) and had Grace-Ann
elaborate on feelings to better understand of how they fit together before
intervening.

THERAPIST:  Briefly, what do you mean when you said youʼd be one of
“those people”?
GRACE-ANN: Someone whoʼs totally disorganized and wrecks things for
other people—a loser.
THERAPIST:  Grace-Ann, remember when during our first meeting I
mentioned how we procrastinate on the little stuff the same
way we do the big stuff?
GRACE-ANN: Yes.
THERAPIST:  This is one of these times. Just because some matters may
seem small this does not mean that they are trivial. The small
 stuff matters in big ways. I want to hear more but also make
sure that we reserve time to come up with a plan for when you
leave here today.
GRACE-ANN: But the fact of the matter is that I messed up and didnʼt get the
candy! Thatʼs not a distorted thought. Itʼs a fact. I waited until
the last minute and I might still wreck things, somehow.
THERAPIST:  Youʼre right, it is Halloween and you did not get candy yet.
That cannot be undone. How you handle this situation is
within your control now and moving forward.
GRACE-ANN: I know but itʼs just frustrating. Itʼs candy today, but everything
goes like this.
THERAPIST:  There are many moving parts here. Let me ask whether you
think that when you go to the store, no one will be anywhere
near the candy section, and the only candy available will be,
how did you put it, “crap candy?” What is a kind of crap
candy, anyway?
GRACE-ANN: Those orangey circus peanut things.
THERAPIST:  That the candy bins will only be filled with crappy, orangey,
circus peanut things? Have you been in a store after
Halloween, Valentineʼs Day, or other candy holiday? Whatʼs
on sale?
GRACE-ANN: Candy.
THERAPIST:  Right, my guess is others will need to buy candy tonight and
the store will have some in stock, which is why so much is left
over.
GRACE-ANN: Yes, but they probably have good reasons; I have no excuse.
THERAPIST:  Grace-Ann, I want to be clear that this in no way minimizes
the importance of this matter for you. I imagine it feels similar
 to your emotions about the work issues youʼve been facing. I
hear your frustration at having to face this sort of thing.
GRACE-ANN: This comes everywhere in my life! I should have a shirt that
says “Iʼm sorry” on the front and “Thanks for understanding”
on the back to handle all the times Iʼve disappointed people.

THERAPIST COMMENTARY: At this point, the therapist

acknowledges Grace-Annʼs desire to handle the immediate Halloween
issue, but uses the collaborative approach to explore the strong emotions
and self-criticisms in more detail to clarify hypothesized schema that may
be operating and interfering with coping, specifically using the Downward
Arrow technique (Burns, 1989).

THERAPIST:  Like I said, I could not keep my CBT union card if we do not
try to learn something from this situation and have a plan for
handling it before you leave today. First, would it be okay if
we take a moment to unpack this situation even more because
it may be relevant to other situations.
GRACE-ANN: Yes, okay.
THERAPIST:  For this exercise, we are going to take one of your thoughts
and assume that it is true and accurate and look at what this
means for you. Are you okay with doing this?
GRACE-ANN: Yes.
THERAPIST:  One of the thoughts you mentioned was having to explain to
Jim and your kids why you were late and seeing Jimʼs “not-
again” look. If this thought is true, what does this mean for
you or what does it say about you?
GRACE-ANN: Iʼm disorganized and unreliable at work and even to my
 family, way more disorganized than is normal.
THERAPIST:  Assuming that this is true, what does this mean for you or say
about you?
GRACE-ANN: It means that my family, my job, my friends . . . nobody can
rely on me to do what I need to do. Jim and the kids will see
again how much worse I am than their friendsʼ parents.
THERAPIST:  Assuming then that this is true? What does this mean for you
or say about you?
GRACE-ANN: That they shouldnʼt depend on me and I donʼt follow through
on promises. I might lose my job, which affects them. They
canʼt trust me, and I canʼt even trust myself to do things that I
set out to do, even just for me. This is what happened in
college, why Iʼll lose this job, and why my family is probably
already fed up with me. Iʼve messed up and failed everyone
and everything that is important in life. Why should they
expect that I will change? I know I donʼt.
THERAPIST:  Letʼs stop the exercise there. How are you feeling?
GRACE-ANN: (tearfully) Sad, angry at myself, rotten. Iʼm being hard on
myself, but I deserve it.
THERAPIST:  (waiting a few moments for Grace-Ann to sit with her feelings)
This exercise is called a Downward Arrow. It takes a thought
that seems plausible on the surface and digs down to see the
deeper theme or core belief. If automatic thoughts are the
weed, the core belief is the root of the weed. Based on what
you said, underneath the candy issue, you believe that you
failed and that no one in your life can trust you. In fact, you
said you donʼt trust yourself.
GRACE-ANN: Hearing it like that it feels harsh, but itʼs justified and true in a
lot of situations.
THERAPIST:  You were diagnosed with ADHD in college when you were on
academic leave, right?
GRACE-ANN: Yes.
THERAPIST:  What happened after you resumed school?
GRACE-ANN: I struggled. I needed more than a year extra to finish, more
than any of my friends.
THERAPIST:  But you finished with your degree.
GRACE-ANN: Yes, but I had a good learning specialist at the learning center
and I couldnʼt have done it without the medications.
THERAPIST:  Yes, but you finished, right?
GRACE-ANN: Yes.
THERAPIST:  What made you persist?
GRACE-ANN: Part of me knew that I was capable of doing the work and
figured I needed a degree, but it wasnʼt easy and my grades
were not great. I wanted to finish to show that I could.

THERAPIST COMMENTARY: This piece of the session highlights the

therapistʼs role to point out incremental gains and the clientʼs strengths that
may be minimized by the client, like with Grace-Annʼs yes-but thoughts.
Within this context of eliciting and affirming the negative reactions but
expanding and reframing them, seeds are dropped for the long-range goals
of understanding and coping with this and other such situations to kindle
hope and self-compassion along with the necessary strategies and skills.

THERAPIST:  That last part sounds like one of the goals you had from Day 1,
to know that you could finish things. Apart from the reality of
any of your frustrations at college, you showed an ability to
 face them, make good use of supports, and move ahead, even
if not in the way you planned. Iʼm not saying it was easy or
even ideal but to point out that this part of your story is true
too. Iʼm guessing you had harsh thoughts about yourself when
you were put on academic leave.
GRACE-ANN: Yes, that was a low point. It was really embarrassing to tell my
parents. I could tell they were disappointed.
THERAPIST:  None of this is to dismiss your strong feelings and try to put a
happy face on all this—they are valid but also show how much
you care, for yourself and your family. It is to point out that
you also were able to adapt, use resources, and do the work to
finish college.
GRACE-ANN: Iʼm tired of having to go through all this and work so hard. It
shouldnʼt be this hard.
THERAPIST:  I can only imagine, especially right now when you are amid
another frustration.
GRACE-ANN: This is nowhere near as bad a college, but it doesnʼt change the
fact I messed up Halloween.
THERAPIST:  Youʼre right that this is the most immediate matter. But, about
tonight, do you think Jim and your children will be fed up with
you and have nothing to do with you?
GRACE-ANN: No, not really. But Iʼll be asked why I didnʼt get candy earlier
and I still need to deal with it.
THERAPIST:  Yes, that is how we work through these deeper beliefs,
changing moments at a time. About tonight, whenever you go
to the store, if you see someone else in line buying candy,
would your thought be “Loser,” “What an awful parent,” or
“Oh, that poor family”?
GRACE-ANN: Other people probably have better reasons for being there.
THERAPIST:  Such as?
GRACE-ANN: Maybe theyʼre divorced, a working parent. Maybe they donʼt
have kids and donʼt worry about what candy they hand out to
trick-or-treaters.
THERAPIST:  Youʼre a working parent. Could Jim have gotten candy? You
also mentioned guilt about crap candy. Iʼm not up with the
particulars of candy giving but is there candy shaming on
Halloween?
GRACE-ANN: Jim offered but he already does so much, I felt I should at least
do this, but once Iʼm home and after making dinner itʼs hard to
go back out, though that is what I should have done.
THERAPIST:  So, even though there is some truth in your reactions, what you
just said suggests there is more nuance. I hear you feeling guilt
about Jim chipping in and offering to help, and you may
discount how much you do at home. This is how schemas
operate—they lay dormant but then a trigger like candy sets
off a cascade of feelings and thoughts, like a hibernating bear
getting hit on the head with a stick and awakening growling
and attacking.
GRACE-ANN: (with a smile) I guess my bear got hit by Halloween candy.
THERAPIST:  Yeah, maybe some crappy, orangey, circus peanuts. (Grace-
Ann laughs) Kidding aside, it will be important to see how this
failure-mistrust reaction is triggered in other situations and
might undermine your many strengths as part of working on
your follow-through and trust in yourself.
The session wrapped up with Grace-Annʼs plan to ask Jim to get candy on his
way home. To address mind reading and comparative thoughts, she crafted some
adaptive reminders, such as “Once home, I can focus on the children and our
family time.” She took heart from her positive schema, that she strives to be a
good parent and partner, even caring about Halloween candy.
Grace-Ann made a lot of progress in CBT and was an active collaborator.
Although her probationary status at work was not lifted, she was not fired;
instead, her performance plan was extended another 6 months, her boss noting
improvements but there remained areas in need of improvement. Grace-Ann
weighed the fit between her skills, weaknesses, and the ongoing demands and
stresses of the job. She decided to look for a new job, eventually finding one as a
practice manager for a small, local dental practice. The smaller, more
personalized setting with a more manageable work pace offered a better fit for
Grace-Ann and her skills.

EVAN

Evan is a 24-year-old college student who is two courses shy of earning his
degree. He was diagnosed with ADHD after his first semester of college, during
which he failed or withdrew from all but one of his classes. Because his final
two courses were offered online during the summer session, he decided to move
back home rather than continue to pay for on-campus housing. He has two part-
time jobs (found for him by his parents) to earn money and add structure to his
schedule.
In addition to the problems in his first semester, Evan has ended up with a
less than full-time course load most semesters because of dropped classes. He
had his best academic year just prior to moving home, when he started both
semesters with a part-time schedule by design. Evan passed his courses, did not
violate attendance policies, and was on-time with assignments. He was helped
by formal academic accommodations and a prescribed ADHD medication. As
Evan was now focused on completing his degree and finding a postgraduation
job, he was referred to a nearby therapist for CBT for adult ADHD.
At his first session, Evan said that he had initially resisted CBT because he
felt as though he had turned a corner in the past year. The medication helped him
focus and his online courses promised to be relatively easy. He resigned himself
to a course of CBT to appease his parents, although he conceded their concerns
were justified, and he admitted that he had struggled with an online course in
past, which he eventually dropped. Evan now was preparing to face two such
courses while working part-time and living at home.

THERAPIST COMMENTARY: Evanʼs case represents issues engaging

in treatment [see Chapter 5, this volume] common for emerging adults with
ADHD [see Chapter 6]. Normative adult transition issues are complicated
by ADHD and changing dynamics with parents. Early sessions focused on
Evanʼs “buy-in” for treatment and the goals he found useful and relevant to
him.

When discussing therapy goals, Evan said that he felt behind his peers, as he
would soon be 25 years old and was unsure of his “adulting” skills. As a first
homework task, the therapist invited Evan to select examples of the kind skills
he would like to develop as well as to look up the syllabus for the coming online
course to sketch out his semester plan.
Evanʼs initial goal was to cultivate better money habits such as opening and
using a savings account so he could eventually live on his own. He had two part-
time jobs but wanted to start to look for a full-time job for after graduation. His
primary goal, though, was to pass his online courses and, in doing so, earn his
degree and take a big step toward independence.
Evan had never worked while taking a class. The concentrated summer
schedule is fast paced compared with schedules for the fall and spring semesters.
Evan and his therapist used an activity chart (e.g., a weekly calendar) to outline
Evanʼs obligations over the first week or two of the summer session. The 168-
hour week was reframed as a budget of $168, and Evanʼs schedule was a
spending plan. This template was prepopulated with classes, work hours, meals,
sleep needs, and other obligations such as CBT sessions and a dental visit. Slots
tentatively earmarked for studying were logged as “appointments” as were those
for time for hanging with friends, practicing guitar, or undedicated down time.
The chart allowed Evan to see his week laid out in front of him.
Evanʼs first reaction to this external representation of his week was, “Wow,
this looks really busy.” The therapist agreed that it was ambitious but pointed out
ample pockets devoted to self-care, sleep, and down time. Taking a page out of
motivational interviewing, the therapist asked Evan whether, in fact, he wanted
to take on such a schedule. Evan was determined to finish school. As he
reviewed the schedule, he saw that he could manage work around his study
needs and each facet of the plan was within his capability to achieve.
The therapist asked Evan for positive examples of how he had handled the
past academic year. Evan said that it was useful to keep in mind that he did not
have to do everything all at once. The therapist used this observation to highlight
the various key pivot points in Evanʼs schedule—plans for attending the online
course, deadlines for uploading assignments, and arrival times for work. Plans
for studying at a public library and navigating other transitions were pinpointed,
including those for discretionary time.
Over the first couple weeks, Evan generally kept up with class and work. In
addition to reinforcing these steps, initial examples of task delays, even minor
ones, were reviewed using the HYDDT form to help Evan stay on track. Evan
found the idea of bounded tasks useful, particularly for assignments. This coping
tactic provided Evan with an alternative mind-set from his typical approach to
schoolwork, which was to wing it and wait to be in the mood to study. He took
to the idea of reframing time (e.g., study for 1 hour), which he tracked with a 60-
minute study-music playlist he compiled. In fact, Evan noticed that he ended up
with much more and higher quality down time by starting and keeping up with
schoolwork.

THERAPIST COMMENTARY: Given Evanʼs initial ambivalence about

CBT, many of these early successes resulted from his personalization of
skills, which spurred his use of them. This was boosted by the therapistʼs
recognition of them and highlighting where Evan exhibited skills that he
 doubted (e.g., to keep to a study plan), along with noting his other
strengths.

At the end of the first summer session, Evan faced his only serious delay
while working on his final paper. He already had a rough idea of main points but
had not yet started a draft. Evan found himself distracted at the public library,
which had been a good study space. He came up with the idea to use the
libraryʼs separate conference room, which was unused most days. He was
friendly with the library staff and has secured permission to use it.
Evan struggled to organize and record his ideas because he was trying to get
the ideas “just right” the first time, which led to procrastination. The therapist
reviewed the three writing modes (see Chapter 6) to help him get unstuck. Evan
agreed to first jot down bullet points to touch an outline. This would be followed
by generative or free writing, getting ideas down, though not necessarily in their
final form. The final writing mode would be editing. Evan admitted that he often
tried to free write and edit, simultaneously.
At the very end of the session, Evan offhandedly mentioned that his father
had caught him smoking marijuana late one night. Evan mentioned that he
smoked to help with sleep, which he had done while living on campus. He knew
his parents did not approve, but they only asked that he not smoke at the house.
Evan said that he wanted to cut down his use of marijuana apart from any social
use out with friends. It was agreed to discuss this further after Evan returned
from a between-semester beach trip with friends. In the interim, he had informed
the therapist that he finished the final paper on time and easily passed the class.
Evanʼs next CBT session came just before the next summer semester began.
After a review of Evanʼs progress, the agenda turned to his use of marijuana as a
sleep aid. The therapist asked Evan whether he viewed it as a problem separate
from being caught by his father—“If you had your own place and smoked when
you had trouble sleeping, would this be something that you would want to
change?” The therapist respected the rules and concerns from Evanʼs parents but
wanted an honest account from Evan about his view on the matter.
 THERAPIST COMMENTARY: The discussion of substance use in
emerging adults with ADHD can be a sensitive one. There is a balance of
maintaining the alliance with determining if there is evidence of use issues
that require a higher level of treatment or an agenda item in CBT. CBT
provides a forum to explore Evanʼs thoughts about his marijuana use (in
the context of various negative effects and other clinical misgivings [see
Chapter 6]). The spirit of informed decision making and an analysis of the
clientʼs use pattern is a good starting point for collaboration, review of
clinical data, and motivation and prospects for change.

Evan said that sleep was a longstanding issue that worsened in college. He
had an erratic sleep schedule at school because he often stayed up late; he would
put off sleep until he could not stay awake. He said that he had trouble waking
up, getting out of bed, and starting his day after a night of smoking, and this was
beyond his typical sleep inertia.
Evan shared a new wrinkle in his view of smoking after his beach vacation
with friends. He said that his friends eschewed their old party mind-set and
partook much more modestly than in the past; instead, they focused on work and
other aspects of their lives. Evan said that he stayed up and slept in later than any
of this other friends, and he had the sense that his friends did more before he got
up than he did all day. Evan vacillated between envy of their adult lives and
confusion about whether he wanted that life for himself, both sides were relevant
to the question of whether he smokes too much marijuana. Evan and the
therapist discussed that emerging adulthood is a daunting time devoted to
defining what is important and meaningful for him. This was set out as a theme
to explore while finishing his class, staring his job search, and facing other
adulting issues.
The focus was on how Evan wanted to spend himself. He did not want to stop
smoking; instead, he agreed to focus on times marijuana use seemed obligatory
(i.e., for sleep). The goal was framed as improving his sleep patterns and making
informed choices about smoking rather than it being the default option. Evan
agreed to track his sleep.
The next few sessions focused on a combination of managing his new online
course and reviewing his sleep habits. Evan said that the local public library was
again his classroom and study station. He sat in the public area (though in a
remote back corner) to view lectures using headphones with the conference
room reserved for assignments requiring more focus. These go-to places were
now habitual implementation targets (e.g., “If I go to the conference room, then I
can spend 10 minutes on the assignment”). He said that the library staff showed
an interest in his progress toward graduation and encouraged him, which he said
helped him get on task.
Evan set a 12:00 a.m. get-in-bed target time and an 8:00 a.m. wake-up-and-
get-out-of-bed time for most days. Although allowing for sufficient sleep, he still
had difficulties winding down, often lying awake in bed for over an hour. The
therapist reviewed with Evan his experience leading up to getting into bed. Even
when working evenings, he was home by 10:30 p.m. and had ample down time.
However, his lead up activities before getting into bed were all over the place,
including sleep-disrupting distractions from being online.
Noting that Evan had been able to create routines to promote studying, the
therapist wondered whether some sort of sleep script might help. Evan was
initially resistant, claiming he should not have to put this much effort into sleep
and waking up. Probing this thought revealed Evanʼs doubts about his ability to
maintain the strategies and tactics once he had to do so on his own. He viewed
them as “weird,” noting his beach friends did not seem to work as hard to be
“normal.” Even though he was confident that he would pass his last class, he
cited a series of yes-but thoughts about postcollege plans (e.g., “Yes, Iʼll have a
degree, but Iʼm not qualified for most jobs”; “Yes, I may find a job, but then Iʼll
have to do it every day, and itʼs not like school where they help you”; “Yes, I
can perform a job like the ones I have now, but these are not careers and do not
pay enough to live on my own”).
The understandable concerns about full-time work would be sorted out by
ongoing coping with academics and adult skills, eventually adapted to specific
job demands. The therapist pointed out that Evan had gained skills that he used
habitually and had personalized, a fact that was leveraged to target his existing
sleep habits and how he ends up in sleep-interfering patterns at night. The point
was made that all the strategies and tactics for adult ADHD are tools meant to
help him or anyone, including his beach friends, to make informed choices and
to act with intention in accord with personally meaningful goals, including sleep.

THERAPIST COMMENTARY: This section illustrates the therapistʼs

highlighting incremental coping improvements and client strengths, which
implicitly focus on Evanʼs budding self-regulatory efficacy and residual
mistrust. Although not identified as such, Evanʼs doubts about his sleep
and finding work after college reflect a hypothesized overgeneralization of
his self-mistrust. As it was more immediately relevant, sleep strategies
were prioritized, which offer opportunities for modifying thoughts,
behaviors, and beliefs that can be used in a job search.

Evanʼs sleep script for getting into a sleep mode focused on readying for the
next day (e.g., laying out work clothes or study materials). He also made sure his
electronics were charging before getting ready for bed as part of the wind-down
routine. In fact, Evan recognized how tired he was once he finally got into bed
but thoughts coursed through his mind, which were not racing or disturbing but
still kept him awake. Some basic relaxation and meditation exercises were
reviewed, though he found light stretching easier to do. Evanʼs use of his
smartphone at night was reviewed to distinguish uses that were sleep promoting
versus sleep interfering. He listened to recordings (podcasts or music), which
quieted his thoughts. It was advised that he only listen to familiar works for
sleep (e.g., comfort media) so as not to be kept awake by novel content.
Evan had periodic awakenings at night, during which he assumed his sleep
was ruined, and this triggered his marijuana use. He was open to coping plans
for such times (e.g., get up for a short time before returning to bed, write out
distracting thoughts, cover clock to avoid sleep math) and, as important,
modifying sleep thoughts (e.g., “Even if I wake up, I will still be rested enough
for the day”). Evan was helped by psychoeducation about historical accounts of
first and second sleep, which normalized middle of the night wakings. Various
principles of CBT for insomnia were used to structure sleep, including the notion
of getting up and out of bed at the appointed time regardless of the amount or
quality of sleep, supported by the finding that individuals typically
underestimate how much sleep they have had in comparison with awakenings
(see Chapter 6).
Evan did not always fall asleep quickly but more often got into bed as
planned and kept to his wake-up time. His use of marijuana as a sleep aid
virtually stopped during the semester, though it remained an option. The
therapist invited Evan to note his smoking at other times to discern when he
smoked due to stress as opposed to when he smoked socially, in the spirit of
informed decision making.
Evanʼs final online course turned out to be more straightforward than the
previous one, with no written assignment other than a final reflection paper. This
was a fortunate turn of events, as Evanʼs focus during the summer shifted to his
job search, with graduation now guaranteed.
Evan faced the fact that his college struggles meant he was not as competitive
a job candidate as other graduates with better grades and stronger resumés. He
introduced a self-imposed abstinence from marijuana due to possible
preemployment drug screenings, which led to a greater focus on skills for
managing triggers, risk factors, and justifications for smoking.
Evan eventually found a job with a friendʼs local start-up company that
promised interesting work and personalized mentorship and support. He shed
one of his part-time jobs after a few months once the start-up provided paid
hours. Evan continued to put money in his savings account while he lived at
home and embarked on his unique, winding adult path.

KURT
 I have all these things I have to do but I canʼt make myself focus! I sit
down and try to do what we discuss in here but it doesnʼt work! My mind
goes all over the place and then I get up and do something else and I know
Iʼm not doing what I need to do! I have people asking me for the things I
promised them, and I say Iʼll do them ASAP but my word means s***
because I still donʼt do it! They must be thinking Iʼm not trustworthy and
not worth paying—and theyʼre right! The meds donʼt help, and I donʼt do
what we talk about in here! I sometimes think this is a waste; Iʼm going to
f*** up anyway, so why not just f****** give up?!
Kurt spewed these frustrations during his 10th session of CBT at sufficient
volume that therapists in adjacent offices heard his tirade loud and clear. Kurt is
in his mid-30s and lives in a rented house with four younger roommates. He
grew up near Philadelphia but moved to Los Angeles when he was accepted to a
prestigious college videography program. His high school academic record was
unremarkable, but he had a singular talent for film and video. He said that his
portfolio likely got him into the program, even though his high school grades
included Cs and Ds due to procrastination and disorganization; he simply
preferred A/V work to school.
Kurt said the college program was the best possible fit, as it was almost
wholly based on hands-on learning and projects, but he was still overdue on
deadlines and late to classes, meetings, and video shoots. He was nearly
suspended during his first semester because he was late providing his final high
school transcript. The videography program required a bare minimum of
traditional classes; Kurt was granted extensions on all of them and barely passed,
but he graduated.
Kurt stayed in Los Angeles, where the status of the program and
recommendations from faculty helped him to get jobs. Initial projects were
relatively low impact but allowed him to quickly build his body of work and
reputation. He supplemented his income with part-time jobs, which he claimed
were easy. However, he invariably quit or was fired because he would fail to
show up for shifts when a competing video/film job came up; he was confident
that he would soon support himself solely with paid work in his field.
Video/film work is very project based, providing interesting, time-limited
ventures. Kurt had a defined role in each project, accountability to others, and a
clear, final product at which point he could jump to a new project. The downside
was that he had to be organized to find new projects and field inquiries for his
services. It was difficult for him to respond to inquiries and set up his next job
while hyperfocused on a project at hand.
Kurt was undiagnosed with ADHD and struggled with the organization and
time management needed to arrive on time, meet deadlines, and keep up with
administrative details (e.g., submitting invoices for payment). He also found it
difficult to curb his frustrations with others and acted impetuous and ill-
tempered when facing hassles involved in projects; he was similarly snarky
when confronted on these matters, which also affected project schedules.
Over the next few years, Kurtʼs video/film work slowly declined, in part due
to poor follow-through on inquiries, which forced him to devote more time to
other jobs. This created a vicious loop of having less time to network and seek
out projects, tasks already difficult for him. He eventually fell behind on rent,
amassed substantial credit card debt, and was forced to move home with his
parents before he turned 30 years old.
After moving back to Philadelphia and finding a room in a rented house, Kurt
pieced together a couple of part-time jobs. His parents supported him financially
as he tried to revive his career, hoping to return to Los Angeles but also seeking
work in Philadelphia and New York. About a year ago, he was hired for a New
York project on the recommendation a former classmate. Kurt did the work but
never submitted an invoice for it. He grew increasingly depressed by what he
viewed as self-sabotaging behavior.
Kurtʼs parents encouraged him to seek out help for his mood. After a few
meetings, his therapist suggested that Kurtʼs mood issues and ongoing problems
might be from undiagnosed ADHD. She prescribed an ADHD medication and
recommended a thorough evaluation, which led to a diagnosis and referral for
CBT for adult ADHD.
Apart from other executive function problems, emotional dyscontrol is a
relevant factor in Kurtʼs case. Whereas his passion for film and video served him
well, he had little patience for details that did not interest him and overreacted to
various hassles he encountered. He recognized his reactions as over-the-top and
he got over them relatively quickly, but this pattern had damaged relationships
and his reputation with others.
During the session in which Kurt unloaded his frustrations, the therapist tried
to summarize and steer the discussion toward problem management. The
therapist settled back and absorbed the outpouring until Kurt paused, took a few
breaths, and apologized for his outburst, and then Kurt noted his exasperation at
his circumstances. The therapist said an apology was not necessary, recapped
Kurtʼs aggravations, noted that it was likely only a snapshot of how frustrating
his difficulties and their effects have been for him, and affirmed that behavior
change is hard work.

THERAPIST COMMENTARY: Emotional dyscontrol seen in adult

ADHD is often more restrained than in Kurtʼs case but may still manifest
in relatively short, sharp outbursts that are disruptive and distracting to the
clientʼs overarching objectives. Impulsivity and emotional dyscontrol
likely overlap insofar as adults with ADHD often describe reaching a point
of feeling overwhelmed by stressors or setbacks. In addition to an empathic
summary, it is useful to explore whether there is anything else pertinent to
the clientʼs emotional reactions in session.

The therapist inquired about any other feelings Kurt wanted to voice. Kurt
said that his ongoing poor follow-through is the main difficulty that interferes
with moving forward in his life outside of work (e.g., dating, health, finances).
He felt shame each time he needed money from his parents, like when a piece of
equipment recently stopped working and he needed to replace it. This was
viewed by Kurt as further evidence he cannot catch a break. He described haste
to catch up to how his life was in Los Angeles, but since he had been home now
for several years, Kurt worried that he might turn 40 or 50 years old and still be
mired in the same situation.
Kurt calmed down but was still antsy and distressed by all he had to do. As it
was the end of the session, he quickly drew up a task plan with the therapist that
involved logging into a weblink Kurt needed to review and sitting and looking at
it, even if he could not focus as well as he would like; they lowered the bar as
much as possible to foster Kurtʼs engagement. The purpose was to see if Kurt
could marshal enough focus to make headway, albeit imperfectly. Kurt still
doubted his ability to face even this single task but agreed to try.
Although he was calmer at the next session, Kurt had his typical bouncy leg
and showed other signs of restlessness. He apologized again for the previous
session and said he quickly got over it afterward. In fact, he used the homework
plan to good effect and was somewhat productive at home after the session. The
therapist noted the fact that Kurtʼs plans and his ability to implement them could
be hijacked by his strong emotions. He agreed and noted that a roommate
pointed out Kurtʼs defensiveness when he gave Kurt a reminder that rent was
due; the roommate said that Kurt was very impatient and pushy when he needed
something.
Kurt conceded that the roommateʼs observation was accurate. The therapist
provided some psychoeducation about ADHD and emotions, including their role
in procrastination. To this end, Kurt said that despite his productivity since last
time, he continued to find pretexts to put off working on the long overdue
invoice from the New York job, which was still a therapy goal. Although he
could not argue if the employer did not want to pay him, Kurt still wanted to
submit an invoice to close the loop on the project and reconnect with the contact
person there.
Kurt and the therapist revisited the HYDDT form, which had been used
before for this invoice, to recraft a plan for facing it. At the next session, Kurt
said he still had not submitted the invoice, though he shared an interesting
observation. When thinking about the invoice, he tried to touch the task by
double checking some particulars of the project, including contact information
for the agency. While sorting through digital files and emails, Kurt felt a wave of
embarrassment and shame at the prospect of reaching out to someone whom he
had presumably disappointed. He described anger at himself and a sense of
sadness and regret at the loss of the opportunity the New York project had
offered him and that he had, in fact, completed the job without being paid. Logic
told him the worst outcome of sending a belated invoice was that it would be
ignored or unpaid, but Kurt expected it to confirm his failure and ruined
reputation. This flood of feelings and thoughts resulted in walking away from
the task and created low spirits and morale for the rest of the afternoon.
Kurt and his therapist discussed how his emotions and corresponding beliefs
added another layer of difficulty to managing ADHD. The interactions of these
factors and his ongoing problems further eroded Kurtʼs sense of self and trust in
his coping abilities. Kurt said that he felt like an impostor during the
videography program. He was one of a few students from outside Los Angeles,
New York, or San Francisco. Despite his strong work, he recalled “squeaking
by” with low grades. Kurt saw his current plight as his comeuppance and a sign
that he really was a fraud.
The therapist summarized back and illustrated a conceptualization of Kurtʼs
description of how ADHD and past and current difficulties fit together. This
included the beliefs he voiced and their link to his experiences and how these
magnify his already strong emotional reactions. Finally, the avoidance of the
invoice was outlined using this understanding.

THERAPIST COMMENTARY: The case conceptualization is a

synopsis of the CBT model that has been modified for adult ADHD. It
provides an opportunity to look at how different facets of the clientʼs
experiences and subsequent cognitive, behavioral, and emotional patterns
fit together. In the spirit of collaboration, Kurt and the therapist decided
together how to best move forward toward Kurtʼs goals using this
conceptualization in the here and now to guide coping plans and skill-
based strategies.
 The therapistʼs summary led Kurt to the “Okay, this makes sense but what do
I do about it?” question. The therapist put it back on Kurt whether he still wanted
to submit the invoice; if so, what was a realistic first step for him? Whatever his
decision, it was framed as an opportunity to face the invoice or let it go, and
work toward experiences with which to rebuild efficacy. They reviewed
examples of Kurtʼs experiences and mind-sets when actively engaged in projects
that provided evidence counter to his failure belief and illustrated his talents.
These examples included the New York job, for which he said the product he
delivered was great and admitted that the overdue invoice overshadowed this
fact. Kurt spoke of the resilience he had in Los Angeles that allowed him to
tolerate critiques of his work and use them to hone his skills and craft. The
therapist pointed out that Kurt exhibited this trait recently by taking to heart his
roommateʼs feedback, which was evidence of his ability to face and tolerate
discomfort to grow and improve.
Kurt said that although he still wants to return to Los Angeles, he could do
more to seek out work on the East coast, including smaller jobs, and he
recognized that he has been avoiding steps he could take to improve his
employability. He and the therapist discussed how Kurt might reach out to old
contacts and friends to network. Kurt worried it would look weird and
inappropriate to suddenly reach out after so much time has passed, but when
asked whether he would view it as weird or inappropriate if they contacted him,
Kurt smirked and said that he would be pleasantly surprised to hear from them.
Kurt decided that he still wanted to close the loop with the New York invoice,
if nothing else to simply face it for his own sake. He realized what he had
viewed as small first steps were still too big with respect to his shame reactions.
Kurt agreed to view the video he sent to the New York agency to remind him of
the quality of his work, like an exposure task. He later noted that after doing so,
he posted some other video footage on his social media accounts.
Emotions played a prominent role in these experiments. Kurt gained practice
noticing and tolerating feelings that arose but endured them to stay engaged in
an endeavor, and found that his emotional fortitude slowly improved. As he took
such steps, he observed mixed emotions that could be discerned and labelled,
including positive feelings of pride in his work and pangs of remorse about lost
opportunities. Cognitive defusion strategies added another layer to coping with
strong thoughts and feelings. He found it helpful to view intrusive thoughts and
feelings as critiques for which he could use his resilience to tolerate without
abandoning a plan.

THERAPIST COMMENTARY: This phase of Kurtʼs CBT reflects the

sufficiency reframes of being able to do enough and tolerate discomfort
while engaging in endeavors. In addition to tolerating discomfort, Kurt was
able to notice and discern adaptive, task-promoting emotions and mind-
sets. He developed more trust in his abilities to face priority tasks that were
the building blocks for higher order goals related to seeking projects as
well as fostering more adaptive beliefs and schemas about himself.

By no means was Kurt a Zen master, but he coped better. He adopted a

method acting approach living in Los Angeles, which was that he tried to act like
someone who already possessed the emotional flexibility he was trying to
muster. The baseball film Bull Durham was a favorite of Kurtʼs, in which a
young pitcher was advised to play the game with “fear and arrogance” as he left
his minor league team to play in the major leagues. Kurt used this as a reminder
he could hold competing feelings. He often had to have such faith in his work
and ideas during the editing process in past jobs, unsure of how the product
would turn out but trusting his vision. He said he now viewed CBT as editing his
outlooks, habits, and emotions.
Several weeks later, Kurt submitted the invoice by email. He received a
notice that it was past the submission deadline and would not be paid. He was
initially bothered by the impersonal response but ultimately gave himself credit
for facing the task. In fact, he later sent a message to his contact in the agency
and received a cordial response and an invitation to “keep in touch.” Kurt felt
that he had not only closed the loop on the invoice, but also perhaps opened a
line communication.
The fact that Kurtʼs therapeutic gains continue to outpace his functional gains
is not uncommon. His difficulties reestablishing his career despite improved
coping efforts are akin to improving spending behaviors while still paying down
large credit card debts—it is progress but requires persistence to maintain,
including facing periodic setbacks, and reach benchmarks on the way to an
ultimate desired outcome.
Kurt is still prone to mood funks when faced with obstacles such as ongoing
financial support or reading accounts on social media. When reviewing options
for side jobs or prospects for steady income as he pursues video/film work, Kurt
still rigidly insisted that he must be fully devoted to his field or he will be out of
the loop, which limited some potential avenues. In the meantime, Kurt
established a website through which he has secured some jobs, including a
wedding (a prospect he would have viewed as an anathema, which reflects some
flexibility in at least entertaining work options). Nevertheless, he has gained
confidence enough to engage in and follow through on such tasks and to do what
he sets out to do more consistently, although he may have more hurdles to face
and endure as he moves forward.

CONCLUSION

These wide-ranging case examples reflect the clinical diversity in the

psychosocial treatment of adult ADHD. CBT provides a flexible model for
helping clients understand and recognize how features of ADHD unfold in daily
life to create the functional difficulties for which they seek psychosocial
treatment. This model also provides a therapeutic framework for fashioning
personalized interventions targeting key pivot points in a clientʼs life at which
the implementation of coping strategies can be most beneficial. Although the use
of such behavioral skills is the main outcome goal, the cognitive component of
CBT was highlighted in the cases reviewed in this chapter.
Grace-Ann faced difficulties following through on work endeavors that were
informed by deeper schemas related to self-mistrust and belief that she had
disappointed others. Evan faced similar self-doubts as he finished his degree
requirements while navigating emerging adulthood. He dealt with self-
comparisons with his peers who seemed better at being an adult and dealt with
longstanding sleep problems managed with marijuana. Finally, Kurtʼs case
reflected the role of emotional dyscontrol in adult ADHD. His emotions and
other executive functioning difficulties magnified and were magnified by his
frustrations with trying to reestablish his career and to establish newfound trust
in his ability to consistently face endeavors. For each of these individuals, the
cognitive domain of CBT for adult ADHD served to personalize their unique
barriers to follow-through and foster engagement in more adaptive coping
approaches that increased follow-through and led to some degree of progress.

FINAL THOUGHTS

As was noted in the Introduction, this book is the long-delayed answer to a

question posed during the Q&A of a workshop in 2002 about the central
cognitive theme in adult ADHD. The answer offered throughout the pages of
this book is that impaired self-regulatory efficacy (and distrust thoughts and
mistrust beliefs) is the central theme underlying the thoughts and beliefs of
adults with ADHD, which has ripple effects on functioning, particularly attempts
to transform intentions into actions.
The broader goal of this book was to outline the role of thoughts and beliefs
in the lives of adults with ADHD and within psychosocial treatment. Its unique
contribution is its emphasis on the role of cognitive change principles within a
CBT approach modified for adult ADHD, chiefly to effect behavior change in
settings in which adults with ADHD have coping and functional difficulties.
CBT for adult ADHD turns managing ADHD into managing pivot points,
with cognitions representing an essential ligament or mediator between intention
and action at these points. This approach serves the same function for therapists
helping adults with ADHD by offering a way to frame and deliver tools, skills,
tactics, and strategies in distinct and doable units of action that clients believe
they can use. Treatment is personalized to the array of individuals and their
unique life circumstances, histories, temperaments, roles, and personal goals, all
of which influence and are influenced by their thoughts and beliefs. As
reportedly said by Hall of Fame baseball player Yogi Berra, “If I hadnʼt believed
it, I wouldnʼt have seen it.”
APPENDIX

Credible Sources of Information

About Adult ADHD

The following is a list of reputable websites and sources of credible information

related to adult attention-deficit/hyperactivity disorder (ADHD) for both
professionals and consumers:

AADD-UK: https://aadduk.org/
ADHD in Adults (Agency for Healthcare Research and Quality):
http://adhdinadults.com/
The American Professional Society of ADHD and Related Disorders:
https://apsard.org/
Association on Higher Education and Disability® (AHEAD):
https://www.ahead.org/home
Attention Deficit Disorder Association (ADDA): https://add.org/
Canadian ADHD Resource Alliance (CADDRA): http://www.caddra.ca/
Children and Adults With Attention-Deficit/Hyperactivity Disorder
(CHADD): https://www.chadd.org/
Learning Disabilities Association of America (LDA): https://ldaamerica.org/
National Attention Deficit Disorder Information and Support Service
(ADDISS): http://www.addiss.co.uk/
National Institute of Mental Health (NIMH):
https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-
disorder-adhd/index.shtml; https://www.nimh.nih.gov/news/science-
news/science-news-about-attention-deficit-hyperactivity-disorder-adhd.shtml
National Resource Center on ADHD (NRC): https://chadd.org/about/about-
nrc/
Totally ADD: https://totallyadd.com/
UK Adult ADHD Network (UKAAN): https://www.ukaan.org/
World Federation of ADHD: https://www.adhd-federation.org/
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ABOUT THE AUTHOR

J. Russell (“Russ”) Ramsay, PhD, is a licensed psychologist and associate

professor of clinical psychology in psychiatry at the University of Pennsylvania
Perelman School of Medicine. In addition to continuing to work as a senior staff
clinician at the Center for Cognitive Therapy, in 1999 he cofounded and still
serves as the codirector of Penn Medicineʼs Adult Attention-
Deficit/Hyperactivity Disorder (ADHD) Treatment and Research Program. Dr.
Ramsay also has authored numerous professional articles and book chapters and
has lectured internationally on various issues related to adult ADHD as well as
the principles of cognitive behavior therapy. Follow @cbt4adhd