Cognitive Behavioral Therapy (CBT) for ADHD

A great book on the effectiveness of cognitive-behavioral therapy, or CBT, for people who have ADHD has just been released in paperback. While it is intended for therapists who want to help people with ADHD to build skills in executive functioning, the first half of the book presents evidence about the areas in life where working adults may struggle and fail, in spite of being talented, articulate and hard-working. It’s called Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction by Mary V. Solanto. She is a psychiatrist at the Mount Sinai School of Medicine in New York City. I’ve taken some important definitions and descriptions from this book which hopefully will shed light on behaviors (usually negative) that you may observe in yourself or your children.

Personally, I am very impressed with the quality of the writing in this book, both by Solanto and her other contributors. She provides evidence of the success of such a program, whether or not the person with ADHD is taking medication or not. She focuses on the challenges that adults face, those adults who did not “grow out of” ADHD (which is estimated to be about half of the population who has ADHD as children – about 8% of the population). I wish there were more programs here in the Los Angeles area which used this approach. While some mental health facilities offer classes on CBT (such as Kaiser Permanente), they do not gear it to the challenges faced by people with ADHD.

“Insufficiency of Medication as a Comprehensive Treatment for ADHD”

Even with medication – which is not effective for all patients with ADHD – there are skills and behaviors which were never learned as children that the medication cannot “teach” the person how to do (pp. 13 – 14). Mainly these are the executive functions or the ability to self-manage: organizing, planning, self-monitoring, accessing working memory, utilizing self-inhibition, shifting/ transitioning attention from one task to another, etc. (p. 14). This lack of executive functions is developmental – many of these skills eventually do “stick” but usually about 2 – 3 years behind their peers. This delay may be caused by a physical difference in the brain. “Structural and functional neuroimaging studies both in adults (Seidman, Valera & Bush, 2004) and in children (Seidman, Valera & Makris, 2005) have revealed deficits in the volume and activation of regions of the prefrontal cortex known to subserve these executive functions” (p. 15).

Some researchers frame this as “a fundamental deficit in inhibitory control” (Barkley, Murphy & Bush, 2001; Nigg, 2006) – whether it is to stop an automatic impulse in a given situation, or to “prevent interference from extraneous stimuli.”  Russell Barkley is a well-known proponent of this description of ADHD: “Inadequate inhibitory control results in a a proneness to respond to immediate external or internal stimuli, and is manifested cognitively as poor working memory, distractibility, failure to carry tasks through to completion, inattention to detail, and ‘careless’ errors. Tasks that are lengthy, multistep, or inherently challenging will be particularly vulnerable to disruption. Inadequate working memory may result in difficulties in monitoring and adjusting current behavior so as to maximize timely progress toward overarching goals” (p. 15).

Another area that medication does not help someone suffering from ADHD is an insensitivity to reinforcement. That is, consequences of current behaviors simply don’t enter their minds. This has been described as having an “elevated reward threshold in ADHD” (p. 16). Another way of looking at this is having a “steeper delayed reinforcement gradient” (p. 16). This means that people with ADHD can’t be satisfied sticking to an unpleasant task with the knowledge that “it will matter later when you apply to college” or “this could help you get a job promotion later.”

An unfortunate word is used medically to describe someone who suffers from two or more disorders simultaneously: “comorbid.” Some practitioners now use the word “co-occuring” which makes more sense and is less… morbid. It is quite common for people with ADHD to develop anxiety or depression, caused by years of failure and underachievement. “Adults with ADHD complete fewer years of education, have higher rates of unemployment… and higher rates of marital separation and divorce. In addition, adults with ADHD have higher rates of substance and alcohol abuse disorders (18%) as well as increased rates of anxiety (51%) and depression (32%; Kessler et al., 2006), and adult women with ADHD are at greater risk for eating disorders (Biederman et al., 2010). (pp. 8 – 9).

All of these symptoms and outcomes are probably well-known to you already, as a parent with a child with ADHD. There is hope, of course, in several types of treatments, starting with medications that help the neurotransmitters in the brain focus better and longer.

CBT is a treatment that is psycho-social; that is, it is information that is taught to individuals who seek to change their behaviors. A person with ADHD may not have that “inner voice” that warns them to keep their mouths shut during a sensitive conversation, or to look at a long-term outcome, or to consider at least three bids before deciding on a contractor. CBT helps people become aware of the specific types of situations that can get them into trouble, then to identify what they normally think and do in those situations, and then to think and do something different – in order to achieve a different (positive) outcome.

CBT is founded on the work of Aaron Beck, Albert Ellis, and others (p. 20). The program described by Solanto in this book has key ingredients to help people make changes in their behaviors:

• Explicit skills training
  • Time management: how to use a planner
  • Time management: how to prioritize activities
  • Organization: how to use the space around you for your work – placement of tools and other materials needed on a daily basis
• Development of Compensatory Strategies
  • Setting up a work environment to minimize distracters
  • Setting a timer to get work done
  • Maximizing important external prompts, like post-it notes or an electronic calendar
• Generalizing positive statements/maxims
  • Use of Take-Home Exercise activities that the person can do by himself
  • Frequent repetition of positive statements so that they will automatically start popping up in the person’s consciousness (development of that “inner voice”), such as “Out of sight, out of mind,” and “Getting started is the hardest part.”

There are many more ideas presented in this book about how to accomplish this “brain training,” including a complete 12-week training manual written for therapists to take a group of participants through these ideas and give them specific and practical tools to change their behaviors.

Hopefully with such a well-written guide now available in paperback (just published in 2013; I received my copy on September 12, 2013), we will see more utilization of this healthy therapy, CBT.

UPDATE 9-16-13: I received a message from the author, Dr. Mary Solanto, who recommended contacting the Association of Cognitive and Behavioral Therapies at www.abct.org to find a cognitive-behavioral therapist in your area. He or she can use this book as a guide to address the specific needs of people with ADHD — building executive functions.