Master Clinician Workshop:
CBT for Adult ADHD
Anxiety Disorders Association of
America
April 11, 2012
Mary Solanto, Ph.D.
Mount Sinai School of Medicine
Mary V. Solanto, Ph.D.
Disclosure of Potential Conflicts
Source Research Advisor/ Employee Speakers’ Books, In-kind Stock or Honorarium
Funding Consultant Bureau Intellectual Services Equity > or expenses
Property (example: $10,000 for this
travel) presentation
or meeting
Shire X
Pharma
Guilford X
Press
Plan
Background and Overview
Rationale
Goals
Underlying Principles
Major Components
Clinical Guidelines
Selection of Candidates
Style of Presentation
Roundtable Inquiry of Home Exercise
Therapist Manual
Overview of Sessions
Modification for Individual Therapy
Rationale for Psychosocial
Intervention
Inadequate medication response or untoward
effects in 20-50% of adults (Wilens, 2002)
Definition of Medication “response”
25-30% reduction in core symptoms
Residual deficiencies in time management,
organization and planning (TOP) skills, even
among medication responders.
Rationale for Psychosocial
Intervention (continued)
Lack of development of “meta-cognitive” skills
in childhood due to ADHD symptoms
(Douglas; Barkley).
Need to address psychiatric comorbidity (e.g.,
anxiety and depression) and related
dysfunctional “automatic thoughts”
Need to address ingrained, maladaptive behavior
patterns, obstacles to change, and psychosocial
impact of ADHD
Targets of Treatment
Problems with time-estimation (late and missed
appointments)
Procrastination, avoidance (failure to initiate)
Failure to complete tasks, especially on boring, routine,
non-gratifying tasks (e.g. bills, laundry, mail, taxes)
Failure to STOP and shift to a new task as appropriate
(failure to inhibit, misnamed “hyperfocus”)
Difficulties with organization (losing and forgetting)
Failure to follow through on long-term projects, life goals
Measured using our “ON-TOP” questionnaire
Goals of Treatment Design
Practical, “real”, easy to assimilate
New meta-cognitive skills must be taught – e.g., filing system,
steps in project planning
New behaviors must be assimilated into all the activities of
daily life in a way that becomes “habitual” and automatic
Neuropsychologically informed
Address impairing self-attributions
Manualized - to be researched & replicated
Solanto, MV. Cognitive-Behavioral Treatment of Adult ADHD: Targeting Executive
Dysfunction. Guilford Press, 2011
Cognitive-Behavioral Group
Treatment – Methods
Impart explicit skills (e.g. filing system)
Impart “rules” (adaptive internal speech) to guide daily
scheduling, prioritizing, self-activation, organization
Contingent self-reinforcement
Visualization of long-term rewards of present behavior
Counteracting steeper delay-of-reinforcement gradient
Use of traditional CBT to address demoralization,
anxiety, and perfectionism
Intensive practice, group support, positive
reinforcement
Treatment Parameters
Group modality (can be adapted for indiv
therapy)
Exclusive focus on “TOP” skills
12-sessions, 2 hours, 6-8 persons
Components of each session
Review of home exercise
Presentation of new material
In-session exercise
Review of upcoming Home exercise
Handouts summarize the session, home exercise
In-Session Exercises
Break down complex tasks into parts
Create a week’s schedule from to-do list
Visualization of distant rewards
Set up a filing system
Sort a stack of papers from a typical desk
Organize a physical space
Plan a project using the flow chart
Prioritization Work Sheet
Estimated
Date/ Priority Scheduled Completed
Task Time
Deadline (1 to 5) for ___ on___
Needed
Project Flow Chart
Home Exercises
Choose one procrastinated task of less than 1
hour, schedule, complete it, and self-reinforce.
Prioritize and schedule task list into a week.
Select a space to be organized, divide into
“zones”; schedule; complete one zone; self-
reinforce.
Plan a project (over 2 weeks) using flow-chart.
“Mantras”
“If it’s not in the planner, it doesn’t exist.”
“If I’m having trouble getting started, then the first step
is too big.”
“All things must be done in the order of their priority.”
“Getting started is the hardest part.”
“A place for everything - and everything in its place”
(organization)
“Out of sight, out of mind” (distraction control)
Efficacy Study
Sponsored by NIMH
Treatment Development Award
88 adults with ADHD randomly assigned to CBT
Group or Support Group
CBT superior via blind evaluator, self- and other-
report
Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K.,
Abikoff, H., Alvir, J. M., & Kofman, M. D. (2010). Efficacy of
meta-cognitive therapy (MCT) for adult ADHD. American Journal
of Psychiatry, 167(8), 958-968.
Candidates
Exclusions (ascertained in pre-group interview)
Other more severely impairing condition -
E.g. severe anxiety, depression, suicidality
Borderline personality disorder
Active alcohol, substance abuse
Anger control problems
?Asperger’s, PDD Spectrum
Extreme verbal impulsivity/insensitivity to social cues
Screening Visit
To confirm diagnosis of ADHD via
Current symptoms
History
Scores on standardized Questionnaires (eg.CAARS)
To ascertain co-morbidities (eg. BDI, BAI)
To prioritize current problems vis-à-vis choice
of treatments
To learn details of current life-situation,
problems, goals.
Style of Presentation
Roles the Leader Plays
Cheerleader
Warmly supportive and encouraging;
Energizing, Exhorting
Teacher
Engaging style of presentation
Socratic method – invites dialogue, active thinking
Always get “real-world” material for Exercise from Group
e.g. for project flow-chart
Use visual cues – white-board for lists, diagrams
Didactic – background, psychoeducational material, mantras etc.
Therapist
Know how to follow up disclosures in HE
Know when/how to probe defenses
Know when to (gently but firmly) hold patients accountable
Know when to let group do the theraputic work
Review of the Home Exercise
Central Importance of the Home Exercise
Sole significant predictor of outcome
Comprises 50% of session
Firm control of timing (need to be assertive)
Exercises are intended to be cumulative
If successful, praise. Solidify by asking:
How did it feel?
What did you do differently this time?
What would you do in the future in same sit?
Review of the Home Exercise cont
If not successful or only partially successful:
Identify and address obstacles.
Realistic or not?
Trouble-shoot and cue the relevant strategy, for example:
“Did you schedule it in your planner?”
“Are you trying to do too much?
“Did you break it down into parts?
“Did you plan to reward yourself afterward?
“Were you trying to work in an area with distractions?
Patterns of non-compliance with HE
Manifestations:
Started, but stopped
Did not start, but wanted to
Did not start and did not want to
Causes:
Classic ADHD
Anxiety about being overwhelmed/failing
Shame at non-completion may lead to missing session
Depression/demoralization
Doubts about self-competency
Unable to summon the “energy of activation”
Oppositionality
Treatment Manual
1. Introduction
Time Management
2. Time Awareness & Scheduling
3. Making Tasks Manageable and Self-Reward
4. Prioritizing and To-Do Lists
5 (5-6) Overcoming Emotional Obstacles (via CBT)
6. Activation and motivation
Organization
7. Setting up Organizational Systems
8. Implementing Organizational Systems
9. Maintaining Organizational Systems
Treatment Manual - cont
Planning
10. Plan a Project
11. Project Implementation
12. Conclusion, Summation, Future Planning
Optional Session:
Going to bed, getting up and getting to work on
time.
Optional Exercise:
Planning a business or week day
Project Flow Chart
Modification for Individual Therapy
Indications
Advantages of Individual Treatment
Allows for focus on specific areas of deficit
Allow for progress at the individual’s pace
Allows opportunity to address resistance
Flexible scheduling, privacy
Contraindications for Group Treatment:
Significant anger management problems
Active drug or alcohol abuse
Other severe psychopathology
Social Phobia (usually self-select out)
Modification for Individual Therapy
Methods
Guided Inquiry of Skills
Corresponds to Hierarchy of Skills keyed to sessions
Hierarchy of Skills Keyed to Sessions
Hierarchy - continued
Modification for Individual Therapy
– continued
Setting and Adhering to the Agenda
Balance between maintaining structure and
responding to current emotional needs/issues
Importance of laying the groundwork
Time Allocation (approximate)
10-15 min for review of Home Exercise
20 min for new material
10-15 for review of new Home Exercise
Modifications for Individual Therapy
Review of the Home Exercise
Share expectation that home exercises will be
challenging
Repeated failure to complete HE signals
emotional issues, resistance
As in Group, query reasons for success/partial
success/failure; expansion of strategies
HE’s can be repeated to mastery
Modification for Individual Therapy
Termination
Decision to Terminate
Mastery of strategies OR
Focus has shifted to emotional /personality issues
Termination Process
Review progress in treatment
Anticipatory trouble-shooting/problem-solving
Spaced follow-up
Eg. monthly for 1st month
Then “as needed”
