CBT for ADHD Uram Family Therapy Michael Uram, MA, LMFT, LPCC Debra Sussman, MA, Associate MFT Rajiv Joshi, MA, Associate MFT

Key Points The percentage of American children aged 2-17 diagnosed with Attention Deficit Hyperactivity Disorder is about 9.4%. The chance that they also meet criteria for another mental health condition is 64%. https://www.cdc.gov/ncbddd/adhd/data.html It is an intention disorder more than an attention disorder. They mean to do the right thing and then do not follow through. The more appropriate term is an executive functioning deficit. Barkley identifies 7 Executive Functioning Skills that are linked with ADHD: https://www.additudemag.com/7-executive-function-deficits-linked-to-adhd/ Here is a self test to assess your executive functioning skills: https://additudenewhopemedia.polldaddy.com/s/self-test-executive-function-deficit- in-adults

Executive functioning skills 1. Self-awareness: Simply put, this is self-directed attention. 2. Inhibition: Also known as self-restraint. 3. Non-Verbal Working Memory: The ability to hold things in your mind. Essentially, visual imagery — how well you can picture things mentally. 4. Verbal Working Memory: Self-speech, or internal speech. Most people think of this as their “inner monologue.” 5. Emotional Self-Regulation: The ability to take the previous four executive functions and use them to manipulate your own emotional state. This means learning to use words, images, and your own self-awareness to process and alter how we feel about things. 6. Self-motivation: How well you can motivate yourself to complete a task when there is no immediate external consequence. 7. Planning and Problem Solving: Experts sometimes like to think of this as “self-play” — how we play with information in our minds to come up with new ways of doing something. By taking things apart and recombining them in different ways, we’re planning solutions to our problems. https://www.additudemag.com/7-executive-function-deficits-linked-to-adhd/

Treatment for ADHD based on cdc’s recommendations Medication 1 Behavioral Therapy and Parent Training 2 School Accommodations and Interventions 3 Monitor Change and Adapt treatment as needed https://www.cdc.gov/ncbddd/adhd/guidelines.html https://www.cdc.gov/ncbddd/adhd/treatment.html#behavior 4

CHADD Recommendations Cognitive Therapy CBT is relevant for adults with ADHD in two ways. First, in recent years, CBT programs have been developed specifically for adults with ADHD. Some of these programs aim to help adults overcome their difficulties in everyday executive functions that are needed to effectively manage time, organize and plan in the short term and the long term. Other programs focus on emotional self-regulation, impulse control and stress management.  http://www.chadd.org/Understanding-ADHD/For-Adults/Treatment/Cognitive- Behavioral-Therapy.aspx

Comorbidity Additionally, it has been well established that adults with ADHD are more likely than adults in the general population to suffer from co- existing anxiety and depressive disorders. A large national study found 51% of adults with ADHD suffered from co-morbid anxiety and 32% suffered from co-morbid depression. Thus, treatments that incorporate CBT for these disorders may be quite helpful to many adults with ADHD, even though they are not designed specifically to address the symptoms and impairment associated with ADHD. http://www.chadd.org/Understanding-ADHD/For- Adults/Treatment/Cognitive-Behavioral-Therapy.aspx

Executive Functions Programs that address executive dysfunction fall into the category of cognitive-behavioral therapy because they impart more adaptive cognitions about how to go about planning, organizing, etc. and also impart more effective behavioral skills. An example of an adaptive cognition is the self-instruction to “break down complex or unpleasant tasks into manageable parts.” Examples of behavioral skills are using a planner regularly and implementing a filing system. Positive thoughts and positive behaviors reinforce each other; as the person becomes more effective in managing time, s/he comes to have more positive beliefs and cognitions about the self, and these in turn help to generate and maintain more adaptive behaviors.  http://www.chadd.org/Understanding-ADHD/For- Adults/Treatment/Cognitive-Behavioral-Therapy.aspx

ADHD Couples Melissa Orlov wrote the best practices for Couples: http://www.adhdinpractice.co.uk/First- line-therapeutic-interventions-for-couples-impacted--by-adult-ADHD Adult ADHD often goes undiagnosed and, as a result, therapists and couples’ counsellors will encounter undiagnosed ADHD in those seeking relationship therapy. The most common ADHD effect patterns are: misinterpretation of ADHD symptoms; chore wars; parent/child dynamics; and mutual denial or ‘the blame game.’ There are three distinct stages that couples go through when coming to terms with the impact ADHD has on their relationship: Stage 1 – getting past the denial; Stage 2 – The hard work ... making structural changes; and Stage 3 – Building romance and connection. 

Expert opinions Russell Barkley has detailed explanations of the latest treatments for ADHD. He is the most prominent expert on ADHD in America: http://russellbarkley.org/factsheets.html Mary Solanto: https://www.ncld.org/archives/mission-and-history/professional-advisory- board/mary-v-solanto https://www.psychologytoday.com/us/blog/here-there-and-everywhere/201210/cbt-adhd- interview-mary-solanto-phd J Russell Ramsay: http://www.med.upenn.edu/add/faculty_ramsay.html Stuart Ablon and Ross Greene developed Collaborative Problem Solving to address parenting Challenging Kids. Both of their websites have great resources for showing empathy, patience and trust: http://www.thinkkids.org/ https://livesinthebalance.org/