Overcoming ADHD in Adolescence: A Cognitive Behavioral Approach, Therapist Guide 0190854529, 9780190854522

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Overcoming ADHD in Adolescence

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P R O G R A M S T H AT W O R K

Editors-​In-​Chief Anne Marie Albano, PhD David H. Barlow, PhD

Scientific Advisory Board Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

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PR O G R A M S T H AT W O R K

Overcoming ADHD in Adolescence A Cognitive Behavioral Approach

THERAPIST GUIDE

SUSAN E. SPRICH STEVEN A. SAFREN

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2020 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-​in-​Publication Data Names: Sprich, Susan E., author. | Safren, Steven A., author. Title: Overcoming ADHD in adolescence : a cognitive behavioral approach therapist guide / Susan E. Sprich, Steven A. Safren. Description: New York : Oxford University Press, [2020] | Series: Programs that work | Includes bibliographical references and index. Identifiers: LCCN 2019053109 (print) | LCCN 2019053110 (ebook) | ISBN 9780190854522 (paperback) | ISBN 9780190854546 (epub) | ISBN 9780190854553 Subjects: LCSH: Attention-deficit disorder in adolescence. | Cognitive therapy. Classification: LCC RJ506.H9 S664 2020 (print) | LCC RJ506.H9 (ebook) | DDC 616.85/8900835—dc23 LC record available at https://lccn.loc.gov/2019053109 LC ebook record available at https://lccn.loc.gov/2019053110 9 8 7 6 5 4 3 2 1 Printed by Sheridan Books, Inc., United States of America

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About

PROGRAMS

T H AT W O R K

Stunning developments in healthcare have taken place over the past several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps inducing harm (Barlow, 2010). Other strategies have been proved effective using the best current standards of evidence, resulting in broad-​based recommendations to make these practices more available to the public (McHugh & Barlow, 2012). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence-​based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001, 2015; Weisz & Kazdin, 2017). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-​based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This series, ProgramsThatWork, is devoted to communicating these exciting new interventions for children and adolescents to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-​by-​step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice.

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In our emerging healthcare system, the growing consensus is that evidence-​based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This therapist guide for the treatment of attention-​deficit/​hyperactivity disorder (ADHD) in adolescents is aimed at clinicians who are familiar with structured approaches to psychotherapy and the use of cognitive behavioral therapy (CBT) with young people. Modules target organization and planning, reducing distractibility, and adaptive thinking—​all with the aim of teaching young clients how to gain and maintain independence. The guide offers information on including parents in treatment, as well as a section on the use of technology to support therapy. This intervention is based on a rigorous program of research demonstrating its effectiveness and was designed and tested by two leading authorities in the science of ADHD treatment. ​Anne Marie Albano, Editor-​in-​Chief ​David H. Barlow, Editor-​in-​Chief Programs ThatWork

References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–​878. Barlow, D. H. (2010). Negative effects from psychological treatments:  A perspective. American Psychologist, 65(2),  13–​20. Institute of Medicine. (2001). Crossing the quality chasm:  A new health system for the 21st century. Washington, DC: National Academy Press. Institute of Medicine. (2015). Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-​based standards. Washington, DC: National Academy Press. McHugh, R. K., & Barlow, D. H. (2012). Dissemination and implementation of evidence-​ based psychological interventions. Oxford:  Oxford University Press. Weisz, J. R., & Kazdin, A. E. (2017). Evidence-​based psychotherapies for children and adolescents (3rd ed.). New York: Guilford.

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Contents

Introduction: Information for Therapists  1 Module 1  The Foundation: How to Better Organize and Plan

Chapter 1

Session 1: An Overview of the Program  23

Chapter 2

Session 2: How Can Parents Help? First Parent/​Adolescent Session  37

Chapter 3

Session 3: Do the Most Important Things First!  47

Chapter 4

Session 4: What to Do When Things Aren’t Getting Done: Breaking Down Tasks and Problem-​Solving  57

Chapter 5

Session 5: How to Organize Everything  65

Module 2  How to Keep Going and Not Get Distracted

Chapter 6

Session 6: Gauging the Attention Span and Delaying Distractions  75

Chapter 7

Session 7: Optimize the Setting  83

Module 3  How to Be a Better Coach

Chapter 8

Session 8: Thinking, Feeling, and Acting  95

Chapter 9

Session 9: Self-​Coaching 

Chapter 10

Session 10: How Can Parents Help? Second Parent/​Adolescent Session  127

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Module 4  Additional Skills

Chapter 11

Session 11: Don’t Put It Off—​Stop Procrastinating  137

Chapter 12

Session 12: Keeping It Going  149

Module 5  Optional Coaching Sessions for Parents Without the Adolescent Present

Chapter 13

Session 13: Parent Coaching Session 1: Between Adolescent Sessions 3–​5  161

Chapter 14

Session 14: Parent Coaching Session 2: Between Adolescent Sessions 7–​9  169

Appendix  175 References  201 About the Authors  207

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Introduction: Information for Therapists

Therapists who are generally familiar with cognitive behavioral therapy (CBT) and/​or who are comfortable following a guided approach to treatment with adolescents are ideal users of this Guide. Merging didactic skill building with strategies for maintaining optimal motivation for change allows for sessions to build off one another, and this is the approach that this treatment takes. Because attention-​ deficit/​ hyperactivity disorder (ADHD) involves difficulties with attention, practice is key. Also, the reason for both a therapist manual and a Client Workbook is to help adolescents with ADHD receive information in two different modalities: verbally from the therapist and in writing in the Client Workbook. Repetition is key to helping adolescents with ADHD learn skills that they can use long enough for the skills to become easy to do. Hence, we recommend that all of the material presented in the Client Workbook also be presented in the treatment sessions, and we recommend that your clients have their own copy of the Workbook so that they can refer back to it for questions that may come up. We are defining the term “adolescent” broadly. This manual can be used with children entering middle school (approximately age 11) up to young adults graduating from college (approximately age 22). There are many places in the Workbook where we explain how to adapt the skills when working with individuals at different developmental levels. Each of the treatment sessions builds on previous ones. If necessary, we recommend spending extra time on skills that have not yet been mastered before moving on to additional skills. The first skills module is on organizing and planning. We consider this module to be the

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foundation for all additional modules, and therefore we recommend spending as much time as it takes for clients to learn these skills in order to maximize the chances of the treatment being a success. We believe that all of these modules are important and that the order in which the sessions are presented is the appropriate way to present the information. However, if you are working with a client for whom it seems to make sense to present the skills in a different order (i.e., the adolescent exhibits difficulties in some areas but not others or experiences significant comorbidity), customizing the approach in a way that makes sense to you and your client will lead to successful treatment.

Background Information and Purpose of This Program Information About the Validity of ADHD as a Diagnosis ADHD is a valid, reliably diagnosed, neurobiological disorder. Psychopharmacologic treatment studies (see Wilens et al., 1998a); genetic studies, including adoption (Cantwell, 1972; Morrison & Stewart, 1973; Sprich, Biederman, Crawford, Mundy, & Faraone, 2000)  and family studies (Biederman et  al., 1991, 1992, 1986, 1987; Faraone, Biederman, Keenan, & Tsuang, 1991; Goodman, 1989; Goodman & Stevenson, 1989; Morrison, 1980; Lahey et al., 1988; Safer, 1973; Stevenson, Pennington, Gilger, DeFries, & Gillis, 1993; Szatmari, Boyle, & Offord, 1993); and neuroimaging and neurochemistry research (e.g., Spencer, Biederman, Wilens, & Faraone, 2002; Zametkin & Liotta, 1998)  and molecular genetic research (see Adler & Chua, 2002) all support that ADHD as a diagnosis meets the guidelines for diagnostic validity standards (i.e., Spitzer & Williams, 1985). The prevalence rate of ADHD in adolescence is estimated to be between 5% and 10% (Centers for Disease Control and Prevention [CDC], 2010; Fergusson, Horwood, & Lynskey, 1993; Murphy & Barkley, 1996; Verhulst, van der Ende, Ferdinand, & Kasius, 1997). ADHD is a psychiatric disorder characterized by impairment in attention, hyperactivity, and impulsivity (American Psychiatric Association, 2013). Previous research suggested that ADHD was a disorder seen only in childhood because, as children matured, they often gained symptom remission (Hill & Schoener, 1996). However, more recent research

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suggests that 50–​80% of individuals who were diagnosed with ADHD as children will continue to be symptomatic in adolescence and adulthood (Barkley, Fisher, Edelbrock, & Smallish, 1990; Barkley, Fischer, Smallish, & Fletcher, 2004; Biederman, Petty, Evans, Small, & Farone, 2010). While ADHD persists into the teenage and adult years, psychosocial treatments have been understudied in teens and adults relative to younger children (Chronis, Jones, & Raggi, 2006; Cuffe et al., 2001). Core symptoms of ADHD include:

Impairments in attention ■ Impairments in inhibition ■ Impairments in self-​regulation ■

These core symptoms yield associated impairments in major life activities such as educational activities and occupational functioning (e.g., trouble with organization and planning, becoming easily bored, deficient sustained attention for reading and paperwork, procrastination, poor time management, impulsive decision making), impaired interpersonal skills (problems with friendships, poor follow-​through on commitments, poor listening skills, difficulty with intimate relationships), and other adaptive behavior problems (less educated compared to ability, poor financial management, trouble organizing one’s home, chaotic routine, leaving jobs or relationships even when they are going well). Additionally, research suggests that adults with ADHD have an elevated risk for substance abuse and engagement in risky behaviors, including risky driving and risky sexual behaviors (see Barkley, Murphy, & Fisher, 2008, for a review).

Diagnostic Criteria for ADHD Generally, a diagnosis of ADHD is made by a mental health professional using the definition set forth in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-​5; American Psychiatric Association, 2013). The DSM-​ 5 lists the symptoms and other requirements needed for individuals to qualify for all of the various psychiatric disorders. To meet criteria for ADHD, individuals must have at least six symptoms out of the nine possible inattention symptoms and/​or six symptoms out

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of the nine possible symptoms of hyperactivity/​impulsivity. If an individual has six or more symptoms in only the inattention category, we would say that they have ADHD, predominantly inattentive presentation. If they have six or more symptoms in only the hyperactivity/​impulsivity category, we would say that they have ADHD, predominantly hyperactive/​impulsive presentation. If an individual has six or more symptoms in both categories, we would say that they have ADHD, combined presentation. In adults, only five of the nine symptoms are required in the inattentive, hyperactive/​ impulsive or combined presentations in order to meet full criteria for ADHD. Inattentive symptoms include such things as failing to give close attention to details, difficulty sustaining attention in tasks, seeming not to listen when being spoken to directly, failure to follow through on instructions, difficulties with organization, avoidance of tasks that require sustained mental effort, frequently losing things, getting distracted easily, and being forgetful. Hyperactive/​impulsive symptoms include fidgeting, leaving seat frequently, feelings of restlessness, being unable to engage in quiet activities, being always “on the go,” talking excessively, blurting out answers, having difficulty waiting in lines, and frequently interrupting. In addition, the person needs to have had at least some of the symptoms before the age of 12, the symptoms need to be present in at least two different settings, the symptoms need to clearly interfere with the individual’s ability to function, and it must be clear that the symptoms are not better accounted for by a different mental disorder (APA, 2013).

Distinguishing Between ADHD as a Diagnosis and Normal Functioning Some of the symptoms just listed sound like they might apply to almost anyone at certain times. For example, many adolescents (or anyone) could be described as sometimes being easily distracted or sometimes have problems organizing. This is actually the case with many of the psychiatric disorders. For example, everyone gets sad sometimes, but not everyone suffers from a clinical diagnosis of depression. To consider

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ADHD a diagnosis for an adolescent, that person must have significant difficulties with some aspect of their life such as work, school, or relationships. Also, to be appropriate for the diagnosis, the distress and impairment must be caused by ADHD and not by another disorder. It is important to conduct a thorough assessment to rule out the possibility that symptoms reflect another psychiatric disorder.

Treatment of ADHD with Medications Although medication can be an effective treatment for individuals of all ages with ADHD, additional treatment efforts are necessary for many with the disorder. This may be particularly true for adolescents (Wilens et al., 2006). In the scientific literature, responders to ADHD medications (i.e., those who are rated as “much improved” or “very much improved”) can still have significant residual symptoms and impairment following medication treatment (Wilens et al., 2006; Chronis et al., 2006). Additional relevant clinical issues with pharmacotherapy in adolescents include side effects and long-​term safety concerns of medication (Lerner & Wigal, 2008). As clinicians weigh the pros and cons of long-​term medication use for each individual child or adolescent client, they share with families the desire for complementary treatments for this age group. Many authors have noted the need for additional research on psychosocial treatments for adolescents with ADHD (Chronis et  al., 2006; Evans, Owens, & Bunford, 2014). In the review by Evans, Owens, and Bunford, the authors differentiate between behavioral treatments in which parents or teachers must manipulate contingencies and training interventions in which skills are taught directly to the individual. The authors of the review say that training interventions may be the preferred mode of treatment for adolescents because (1)  adolescents encounter numerous teachers, (2)  parents monitor adolescents less closely, and (3) it is sometimes difficult to come up with salient rewards for adolescents. Thus, our treatment program is aimed at addressing this need.

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Development of This Treatment Program This program was developed and initially tested at the Cognitive Behavioral Therapy Program at the Massachusetts General Hospital (Harvard Medical School), Department of Psychiatry. We initially studied the use of this program with adults with ADHD. After we found promising results from our adult studies, we modified the treatment program for use with adolescents. We tested it in a small set of adolescents and used it in our clinical practice to adapt it into a manual. We also conducted a small randomized controlled trial (described later) of the treatment, and we refined this current version of the therapy guidelines.

Organizing and Planning Many adolescents with ADHD find that they have problems with organizing and planning:  difficulties figuring out the logical, specific steps to complete tasks that seem overwhelming. For many adolescents, this difficulty turns into a pattern of giving up, procrastinating, experiencing anxiety, and even experiencing feelings of incompetence and underachievement. For example, our adolescent clients often report difficulties with completing long-​term assignments at school and filling out college applications.

Distractibility The problems with distractibility primarily involve problems in school and when completing homework. Many of our clients report that they do not complete tasks because other less important things get in the way. Examples might include sitting down at one’s computer to work on a paper or a project but constantly going on the internet to look up certain websites or browse social media sites. One adolescent who completed our program reported that he tried to do his homework while watching a show on his computer with his phone sitting on his desk

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next to him. He reported being surprised that it took him many hours to complete his assignments (much longer than he felt it should take).

Mood Problems (Associated Anxiety and Depression) Secondary to core ADHD symptoms, many of our clients have mood problems. These problems involve worry about events in their lives and sadness regarding either real or perceived underachievement. Many adolescents with ADHD report a strong sense of frustration about tasks that they do not finish or do not do as well as they feel that they could have done.

Research on This Treatment Program We first developed this treatment for adults and then adapted it to work with adolescents. With adults, we conducted two randomized controlled trials. The first (Safren et al., 2005) compared the effect of intervention plus continued medications to continued medications alone in 31 adults with ADHD. Based on successful results, the next study was a larger 5-​ year full-​scale efficacy study comparing the adult version of this intervention (CBT to a comparison treatment [relaxation plus educational support; RES] plus continued medications; see Safren et al., 2010). In both studies, the CBT condition outperformed the comparison condition on the hypothesized outcomes using independent assessor-​rated ADHD symptoms and severity. While we were working on the trials with adults, we began adapting our program for use with adolescent clients. We felt that many of the skills that were helpful to our adult clients would be useful for our adolescent clients, yet modifications were needed to reflect the different developmental stage of the adolescent clients. First, we developed ways to include parents in several full treatment sessions and at the end of each session. This expanded on the single session that we include in the adult treatment for involvement of partners or spouses. However, for adolescents, we felt that it would be important to involve parents to a greater extent so that they could be aware and

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supportive of the skills that the adolescents were learning. Parents and their adolescents with ADHD often have difficulties with communication (Robin, 1998). Parent involvement gives clinicians an opportunity to provide guidance to both parents and adolescents around these issues. This involvement also allowed for problem-​solving around how parents could provide positive social support to their adolescent child versus negative social support, something similar to what we worked on with the spouses/​partners of adults with ADHD. A major set of modifications involved prioritizing school homework assignments and focusing on strategies to stay organized with schoolwork. We emphasize self-​coaching (Otto, 2000)  to help adolescents think more adaptively about their work and mentally prepare for what they need to do while avoiding negative thinking. Finally, we incorporate the use of technology (apps, websites, and programs that can be used with phones, tablets, and laptops) when possible to help adolescents keep track of their tasks and meetings/​appointments. With respect to researching this program with adolescents, first we conducted an open pilot trial of this treatment program with three adolescents (Sprich, Burbridge, Lerner, & Safren, 2015). We found that the treatment was well-​tolerated by participants and that they experienced benefit from participation as evidenced by lower scores on ADHD symptoms and improved clinical global impression scores. This study laid the groundwork for our larger randomized trial of this approach (Sprich, Safren, Finkelstein, Remmert, & Hammerness, 2016). In the Sprich et al. (2016) study, our results showed that CBT is an effective psychosocial treatment for adolescents who have ADHD. Study participants included 46 adolescents between the ages of 14 and 18 with a primary diagnosis of ADHD who were stabilized on medication for ADHD. Participants completed 10 individual CBT sessions (with parents coming in for the last 10 minutes of each session) and two sessions that included both the adolescents and their parents for the full sessions. We also offered two optional sessions with parents only. Our results indicated improvements on the three outcome measures: independent evaluator (IE)-​rated parent assessment of symptoms, IE-​rated adolescent assessment of symptoms, and IE-​rated overall stress and impairment of adolescent symptoms.

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About Cognitive Behavioral Therapy Although this therapist manual is designed for therapists with some experience with CBT, some important information is presented here. Many of the adolescents with ADHD and their parents will not have heard about CBT. For those who have heard of CBT, they may imagine other types of CBT, such as CBT for anxiety that involves conducting exposure therapy. CBT for ADHD involves working with the adolescent directly to teach skills and also working with parents to change parent behaviors and reinforce adolescent skill use. The percentage of time spent on these activities may vary depending on the age and developmental level of the adolescent and the needs of each individual family. A good proportion of adolescents may have tried other types of therapy, such as supportive therapy or psychodynamic psychotherapy. In order to lay the groundwork for an approach that is likely quite different from previous approaches they have tried (i.e., the sessions have an agenda, the treatment is modular, and the treatment requires active practice outside of the session that is considered to be as important as or more important than what is done in the session itself ), we find it important to be able to answer questions about the model behind the treatment approach. Some of this information is also presented in the Client Workbook.



The cognitive component of cognitive behavioral therapy:  Cognitive components include thoughts and beliefs that can exacerbate ADHD symptoms. For example, a person who is facing something that they will find overwhelming might shift their attention elsewhere or think things like, “I can’t do this,” “I don’t want to do this,” or “I will do this later.” These thoughts contribute to negative feelings, which can interfere with successful completion of the task. Part of this treatment involves coming up with different ways to think about things that are more adaptive. ■ The behavioral component of cognitive behavioral therapy:  Behavioral components are behaviors, or things people do, that can exacerbate ADHD symptoms. The actual behaviors can include things like avoiding doing important tasks or not keeping an organizational system. CBT aims to recognize unhelpful behaviors and help the adolescent identify and implement more effective behaviors. ■

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History of Failure Underachievement Relationship problems

Negative thoughts and beliefs (e.g. negative self-statements, low self esteem)

Core (Neuropsychiatric) Impairments in Attention Inhibition Self-Regulation (impulsivity)

Mood Disturbance Depression Guilt Anxiety Anger

Failure to Utilize Compensatory Strategies – examples: Organizing Planning (i.e. task list) Managing procrastination, avoidance, distractibility

Functional Impairment

Figure I.1 The Cognitive Behavioral Model of ADHD. Repeated home practice of both cognitive and behavioral strategies is essential for creating long-​standing changes.

Cognitive Behavioral Model of ADHD Figure I.1 illustrates the Cognitive Behavioral Model of ADHD.1 Listed here is an explanation of each of the components of the model:

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Core neuropsychiatric impairments—​starting in childhood—​that prevent effective coping:  Adolescents with ADHD have been suffering from this disorder chronically since childhood. Specific symptoms such as distractibility, disorganization, difficulty following through on tasks, and impulsivity can prevent people with ADHD from learning or using effective coping skills.

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Originally published by Safren, Sprich, Chulvick, & Otto (2004).

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Lack of effective coping can lead to underachievement and failures: Because of this, clients with this disorder typically have sustained underachievement or things that they might label as “failures.” ■ Underachievement and failures can lead to negative thoughts and beliefs:  This history of “failures” can result in the development of overly negative beliefs about oneself as well as negative, maladaptive thinking when approaching tasks. The negative thoughts and beliefs that ensue can add to avoidance or distractibility. ■ Negative thoughts and beliefs can lead to mood problems and can exacerbate avoidance: Therefore, people shift their attention even more when confronted with tasks or problems, and related behavioral symptoms can also get worse. ■

The Role of Medications The adolescent treatment approach depicted in this manual was tested on individuals who were already diagnosed with ADHD and on medication for ADHD. We have found that it is important to inquire about regular medication use and to discuss the importance of adherence to medications—​especially in the case of stimulants, which are typically short-​acting agents. We have no reason to believe that this treatment would be contraindicated in unmedicated adolescents. However, as with other aspects of learning new skills that involve attention, it is likely that medications would “turn the volume down” on symptoms a bit and facilitate learning these CBT skills. Medications are currently the first-​ line treatment approach for ADHD, and they are the most extensively studied. However, a good number of individuals (approximately 20–​50%) who take medications for ADHD are considered nonresponders. A  nonresponder is an individual whose symptoms are not sufficiently reduced by the medications or an individual who cannot tolerate the medications. Additionally, individuals who are considered responders typically show a reduction in only 50% or fewer of the core symptoms of ADHD. Further, nonadherence to medication treatment is a significant problem in adolescents with ADHD (Thiruchelvam, Charach, & Schachar, 2001). In one recent study, Winterstein et  al. (2008) found that slightly less than half of youths with new prescriptions 11

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for ADHD medications were still receiving medications after 1 year, and only 17.2% were still receiving medications for 5 years or more. Another important consideration in using medication to treat adolescent ADHD is that stimulant misuse and diversion has been documented in this population. For example, in a review article, Wilens et al. (2008) reported lifetime rates of diversion that ranged from 16% to 29% (students with stimulant prescriptions who were asked to give, sell, or trade their medications to others who did not have prescribed stimulants). Recent data have emerged to suggest that combined medication and behavioral treatment has the best long-​term outcomes in terms of functional impairment in children with ADHD (Hinshaw & Arnold, 2015). A  recent meta-​analysis of pharmacological and nonpharmacological studies of individuals with ADHD found that the combination of pharmacological and nonpharmacological treatment was most consistently associated with improved long-​term outcomes and large effect sizes (Arnold, Hodgkins, Caci, Kahle, & Young, 2015). Because of these data, recommendations for the best treatment of ADHD include using psychotherapy with medications. Medications can reduce many of the core symptoms of ADHD: attentional problems, high activity, and impulsivity. However, medications do not intrinsically provide clients with concrete strategies and skills for coping. Furthermore, disruptions in overall quality of life, such as underachievement, academic difficulties, economic problems, and relationship difficulties associated with ADHD call for the application of additional ameliorative interventions.

Outline of the Different Modules The treatment involves four core modules:  (1) psychoeducation/​ organizing and planning, (2)  coping with distractibility, (3)  cognitive restructuring (adaptive thinking), and (4) parent/​adolescent sessions. In addition, we include an optional session on procrastination and two optional parent-​only sessions, plus a session on how to maintain gains following the completion of treatment.

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Organization and Planning The first part of the treatment involves organization and planning skills. This includes skills such as:



Learning to effectively and consistently use a calendar ■ Learning to effectively and consistently use a task list ■ Working on effective problem-​ solving skills including: (1) breaking down tasks into steps and (2) choosing a best solution for a problem when no solution is ideal ■ Developing a triage system for necessary papers ■ Developing organizational systems for papers, electronic files, and other items ■

Managing Distractibility The second part of treatment involves managing distractibility. Skills include the following:



Determining a reasonable length of time that a client can expect to focus on boring or difficult task and breaking tasks down into chunks that match this length of time ■ Using a timer, cues, and other techniques (e.g., distractibility delay) ■

Cognitive Restructuring (Adaptive Thinking) The third part of treatment involves learning to think about problems and stressors in the most adaptive way possible. This includes:

Positive “self-​coaching” Learning how to identify and dispute negative, overly positive, and/​or unhelpful thoughts ■ Learning how to look at situations rationally and therefore make rational choices about the best possible solutions ■ ■

At times, adolescents can also exhibit extremely positive reports of their own competence that do not correlate with objective measures of actual competence, a phenomenon known as the positive illusory bias (PIB; for

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a review, see Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007). This is addressed by helping the adolescent understand when these overly optimistic thoughts occur and helping the adolescent label them and respond with more realistic/​effective thoughts.

Parent/​Adolescent Sessions The sessions with the parent(s) and adolescent are designed to provide education to the parent(s) about ADHD and the treatment program, to make sure that the parent and adolescent are “on the same page” in terms of their goals for treatment, and—​depending on the age and developmental level of the adolescent—​to develop a contingency management system and to discuss school accommodations. The parents are also brought in at the end of all of the individual sessions with the adolescent so that they can learn about the skills that the adolescent is working on and can assist with skill generalization outside of the treatment sessions.

Application to Procrastination Optional Session 11 exists for procrastination. We include this material because even though most of the previous sessions do relate to procrastination, some people require extra help in this area. This session therefore specifically points to how to apply skills learned in the earlier sessions to the topic of procrastination.

Parent-​Only Sessions The optional (highly encouraged) parent-​only sessions are provided at the request of the parent or if the therapist feels that it would be helpful to speak with the parents without the adolescent present. At times, parents can become extremely frustrated with the adolescent with ADHD and can express sentiments that are unhelpful and are likely to interfere with the motivation of the adolescent to engage in treatment. In these instances, it can be useful for the therapist to speak with

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the parents alone to allow them to vent their frustration, to provide psychoeducation, and to conduct motivational interviewing to enhance parent motivation to engage in the treatment program. These sessions can also be used to discuss such topics as educational planning, use of the contingency-​management system, and limit-​setting.

Involvement of Parents As just noted, parents are involved in all sessions for a small portion of the session and in at least two full parent/​adolescent sessions. Additionally, parents are offered two parent-​ only sessions when needed. The ways in which parents are involved in treatment will vary depending on the age and developmental level of the adolescent. In general, there is more parent involvement with younger adolescents than with older adolescents. Also, if the adolescent and parents have a relationship marked by a lot of conflict, parent involvement should be handled with care. It is important that the adolescent not view the therapist as someone who is closely aligned with parents and teachers and who is simply going to nag the adolescent in an unhelpful way.

Effectively Delivering CBT to Adolescents with ADHD Adolescents with ADHD can be a challenging population with whom to work for many of the reasons already noted. Since adolescents with ADHD are often fidgety and inattentive, it can be difficult to engage them in treatment. The following strategies can be helpful in engaging the adolescent with ADHD in treatment and ensuring that the adolescent understands and retains the information:



Use interactive tasks. Rather than simply presenting information to the adolescent, it is useful to engage them in an interactive task such as completing a worksheet. It is preferable to have the adolescent write or engage in the task rather than having the therapist write and the adolescent look on passively. ■ Role-​ play home practice assignments. Again, providing the opportunity to actively practice the skills will make it more likely that the ■

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adolescent is able to successfully practice the skills in the “real world” outside of the therapy sessions. ■ Have the adolescent repeat information back to make sure that they have understood it correctly. This will also facilitate retention of the information. This can be done when parents are brought in at the end of the adolescent-​only sessions (e.g., have the adolescent explain the skills and practice assignments to the parents).

Structure of Sessions The following activities are included in each session:



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Setting an agenda:  It is important to begin each session by setting an agenda. This helps maintain a structured focus on treatment for ADHD and prepares the client for what lies ahead in the upcoming session. One of the challenges in this treatment is to avoid getting distracted by discussions of other problems that clients may be facing. At times, these problems are pertinent to their ADHD difficulties and can be addressed in the context of the session topics. At other times, it is necessary to convey empathy regarding a client’s difficulty and acknowledge that one of the limitations of this treatment is the need to remain focused so that there will be enough time to go over the skills to manage ADHD symptoms. Inevitably, this means not having time to go into other topics. We recommend assisting the client in identifying other people to whom they can turn for support around other difficulties. ■ Monitoring of progress:  This treatment approach involves regularly monitoring improvement. By administering a measure of ADHD symptoms each week, you, as a therapist, can determine whether the skills are helping. Items that do not change on the ADHD assessment can be targets for further discussion. Highlighting symptom reduction (no matter how small) also serves to enhance clients’ motivation to continue therapy and engage in home practice assignments. To assess ADHD symptoms, you can use the Adult ADHD Self-​Report Scale (ASRS) Symptom Checklist, which is a checklist based on the 18 DSM-​IV-​TR symptoms of ADHD. The link for the ASRS at the time of this writing is https://​med.nyu.edu/​psych/​sites/​default/​files/​ psych/​psych_​adhd_​checklist_​0.pdf. ■

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There are several other brief measures of ADHD that you might wish to use, such as the ADHD rating scale-​5 (DuPaul, Power, Anastopoulos, & Reid, 2016). Feel free to utilize any measure of ADHD symptoms that you use in your practice or clinic—​the most important thing is that you are assessing ADHD symptoms regularly. We find it important to start each session with a discussion of the current symptom score and a review of the homework. Since functional impairment is often present in adolescents with ADHD, it can be useful to assess this in addition to assessing symptoms. To assess functional impairment, the Weiss Functional Impairment Rating Scale Self-​Report (WFIRS-​S; Weiss, 2000) can be used. ■ Review of skills: Each session will also begin with a review of clients’ progress implementing skills from each of the previous sessions. It is important to acknowledge successes and to problem-​solve any difficulties they may be having. Repetition of new skills is critical for individuals with ADHD and will maximize gains made in treatment and increase the likelihood of sustaining improvement. ■

Additional Discussion Points Regarding the Treatment Distractibility Not every topic can be covered at once. Because the treatment approach is modular, adolescents and parents may have areas of difficulty that will not be addressed until future sessions. The program typically starts with implementing a calendar and task list. This module also involves learning organizing and planning skills. The next module is on distractibility. People sometimes have problems with the first module because they get easily distracted, and this is not covered until the next module. This is something that we discuss in the first module. We present it here because it is a point that can come up in different sessions as the treatment progresses.

Motivation Is Key As part of the treatment program, it is important that your client understands how each skill will specifically help them. We utilize aspects 17

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of a motivational interviewing framework integrated into CBT (Naar & Safren, 2017)  to help clients stay engaged and, potentially, resolve ambivalence about change. This is a very structured treatment, and, in the style of motivational interviewing, it is important to enhance and help strengthen the client’s intrinsic motivation for change. Taking such an approach involves trying to, as much as possible, elicit the client’s own motivation for change as you guide them through home practice and didactic content. As with any CBT treatment, if the client is not motivated or does not understand how each specific skill can benefit them, it will be extremely difficult to have them do the work outside of the sessions. The exclusive focus of this treatment is to help clients do things differently outside of the treatment itself. In motivational interviewing (Miller & Rollnick, 2012), for example, one important skill is the “Ask, Tell, Ask” framework (ATA). This involves the therapist asking a question, eliciting a response, telling the didactic information, and then asking another question. For clients with ADHD, this can be especially useful to keep them engaged, as the following example dialogue illustrates: Therapist:  You were just telling me a lot about the difficulties that you have had due to ADHD. Would it be okay if I provide some information about the treatment? (ask) Client:  Yes, that would be great. I really need some help with this. Therapist:  Ok. So the first thing that we are going to do is help you organize where you need to be and when, as well as keeping track of your tasks. We’ll need to come up with a good system for this that we can continue to tweak as we go along. (tell) How does that sound (ask)? Client:  I think that would be useful. I have tried things like this in the past, but do think I could get back into this kind of thing. Using a motivational interviewing framework as much as possible makes the process of change a product of the client’s own desires versus those of the therapist. Accordingly, throughout the treatment, you should try to elicit verbalizations about change and help the client see the solutions versus prematurely problem-​solving for the client, which would not be as effective as having the client be more actively involved in the treatment process (see Naar & Safren, 2017).

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Use of the Client Workbook The Client Workbook will aid you in delivering this intervention. It is set up in a session-​by-​session format that corresponds with the sessions in the Therapist Guide. You will learn, however, that at times variability in the order of the modules is required. We have planned the session content so that an optimal amount of information is presented in each session. We have found that some clients cannot take in a lot of new skills in any one session. We have also found that it is important to leave enough time for problem-​solving regarding material from previous sessions, provision of psychosocial support, and “coaching” around the fact that, given the modular framework, not all skills can be learned at once. Finally, limiting the amount of new information in each session allows for the practice of relatively few skills per week and allows you to present all the information even when client distractions emerge. At various points throughout the sessions, we reference worksheets for the client to complete. These worksheets can be found in the Appendix at the end of both the Therapist Guide and the Client Workbook. The appendices are the same in both volumes, but since the Workbook has larger pages, the worksheets are larger and easier to complete.

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MODULE 1

The Foundation

How to Better Organize and Plan

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CHAPTER 1

Session 1: An Overview of the Program

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 1: Goals of CBT ■

Session Outline

Set agenda ■ Provide information about ADHD ■ Determine client’s goals for cognitive behavioral therapy (CBT) for ADHD ■ Discuss the structure of the sessions ■ Explain modular format (some difficult areas will not be addressed until future sessions) ■ Help problem-​solve potential difficulties with the treatment itself ■ Review motivation for change ■ Discuss use of medications to treat ADHD ■ Introduce the calendar and task list systems ■ Discuss parent involvement in treatment ■ Identify potential pitfalls ■ Agree on home practice activities and anticipate difficulties using these techniques ■

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Set Agenda It is important to begin each session by setting an agenda. This helps maintain a structured focus on treatment for ADHD and also prepares the client for what lies ahead in the upcoming session. One of the challenges in this treatment is to avoid getting distracted by discussions of other problems that clients may be facing. At times, these other issues are pertinent to their ADHD difficulties and can be addressed in the context of the session topics. Because setting an agenda at the beginning of each therapy session might be new, particularly for adolescents in therapy, it is necessary to convey empathy regarding their difficulties and acknowledge that one of the limitations of this treatment is the need to remain focused so that there will be time to present all of the skills to manage ADHD symptoms. Inevitably, this means that there is not enough time to go into other topics. Assist the adolescent client in identifying other people to whom they can turn for support around other difficulties. Again, in the spirit of motivational interviewing, while giving information and setting the agenda are necessary for CBT, engage the client in the process and make sure that you are actively asking the client questions along the way. This process helps to ensure that the client feels the treatment is being delivered in a collaborative way. For this session, the agenda involves providing an overview of the treatment and psychoeducational information about ADHD, doing a motivational exercise, and assigning homework.

Provide Information About ADHD You should provide information about the ADHD diagnosis here. This involves a discussion of our view of ADHD in adolescence. Important points to emphasize include:

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That it is a neurobiological disorder; That it is a valid diagnosis; ■ That it is not related to laziness or lack of intelligence; and ■ That evidence suggests that this type of structured approach can help with symptoms. ■ ■

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The treatment therefore involves actively learning skills. These skills need to be practiced regularly in order for the client to improve. The point is to get a system started and stay motivated to keep it going. It is important to convey the point that people with ADHD do have skills—​ but they need to stay motivated to develop a workable system and keep using it.

Determine Client’s Goals for CBT for ADHD We view this section as a discussion to maximize the fit between the treatment approach and the adolescent’s goals. The Client Workbook (see Chapter 1) lists similar questions, and Worksheet 1: Goals of CBT, in the Appendix, is a grid for assisting the client in determining how realistic each goal is. One of the columns in the worksheet is for “controllability.” In determining the goals, it is essential to focus on goals that are controllable. For example, a goal of “getting into college” depends on many things, including one’s grades, one’s standardized test scores, and other factors. A more controllable goal would be to do as much as possible to maximize one’s chances of getting into the college of one’s choice. This can be operationalized later in the problem-​solving section by identifying steps such as studying for standardized tests, becoming involved in extracurricular activities, and so on. Please refer to Figure 1.1 for some examples of goals that clients might set for treatment.

Questions to Help Client Come Up with Goals It is important to acknowledge that many adolescents with ADHD are not self-​referred for therapy. They are generally referred by parents, teachers, or medical professionals. As such, they are not always motivated to participate in treatment. It is important that you use motivational interviewing strategies to help increase the adolescent’s willingness to engage in treatment. If the adolescent can come to see that their symptoms are interfering with their long-​term goals, they will be more motivated to learn skills to address these symptoms. The following questions may be useful with respect to helping a client come up with their treatment goals: 25

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Figure 1.1 Example goals of cognitive behavioral therapy (CBT).

What made you decide to start this treatment now? ■ In what ways would you like to approach tasks differently? ■ What are some issues that others have noticed about how you approach tasks? ■ If you did not have problems with ADHD, what do you think would be different in your life? ■

Discuss the Structure of the Sessions At this point in the session, provide an overview of the structure of the sessions and provide some information about how the client can get the most out of treatment. Address the following points in this discussion. After approximately each 3–​4 sentences, stop and ask the client how they feel about that point, if they understand it, and/​or if they have any questions. This should be a general rule for you as a therapist throughout the didactic parts of the treatment (few sentences, check in with client, repeat if necessary, and/​or move on and give a few more sentences).

The Therapy Will Be Structured: Almost Like Going to a Tutor or Coaching Session Every session has an agenda, and we will follow specific topics in each session. The topics are also covered in the accompanying client workbook. We put the information in both places so that clients can 26

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easily refer back to the workbook to look up answers to questions that they may have forgotten, and so that they can get additional practice. Although all of the sessions’ contents are included in the Client Workbook, we recommend that you discuss the importance of not reading too far ahead and trying all of the new skills at once. You should check in with the adolescent with questions such as “How does this sound?” and “What questions do you have?” You should also say something like: Additionally, since this treatment is structured and like going to a tutor or a coach, at the beginning of each session we will need to set an agenda. At that point I will bring up what is usually done in this session, but also will want to know from you if there are things that you feel are important to discuss, and if the agenda seems to make sense. How does this sound? The Therapy Involves Home Practice As discussed in the introductory materials, the therapy involves home practice. We consider the home practice to be as important as, or even more important than, attendance at the sessions. Hence, each session involves a review of the previous week’s home practice and a review of the skills that have already been presented in the therapy, as well as things that the adolescent is going to practice on their own for the upcoming week. This increases accountability. If the client knows that skills will be reviewed the following week, they will have more incentive to commit time to practicing the skills at home. When coming up with home practice assignments, it is important to develop the weekly goals in collaboration with the adolescent and present these not as “assignments” that you are giving to the adolescent, but instead as mutually agreed upon skills to try and see if they work better than what the adolescent has been doing in the past. The Therapy Involves Regular Monitoring of Progress We recommend administering an outcome measure at each session. As noted in the Introduction, we use the Adult ADHD Self-​Report Scale 27

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(ASRS) Symptom Checklist, which can be accessed at the time of this writing by clicking on the following link: https://​med.nyu.edu/​psych/​ sites/​default/​files/​psych/​psych_​adhd_​checklist_​0.pdf. Alternatively, feel free to use any measure of ADHD symptoms that you use in your practice or clinic. If you are using the ASRS, go to the web link, print out the most current version of the scale, and make copies so that you can have the client fill it out at the start of each session. Then review the total score and compare it to previous assessments so that progress can be measured. You can also identify any target areas that have not been resolved. Problem-​solving any difficulty with home practice assignments or skills learned will help lead to improvement. One point to mention regarding improvement, however, is that sometimes, when clients do CBT, they expect that improvement will be linear. For example, they expect that their symptoms will decrease by 10% each week for 10 weeks, and then be 100% improved. However, this is rarely the case. Typically, there are ups and downs along the way—​life events occur and skills take time to practice and master. When there is a “down,” this is definitely not a time to quit; instead, this is a time to learn from the factors that led to the setback and figure out how to handle them in the future. This is extremely important with respect to managing expectations. Setbacks that occur in the context of treatment can be viewed as important to treatment planning: they identify areas that can be targeted for additional problem-​solving and the development of coping skills. Do review progress in a collaborative way. For many adolescents, it can be very off-​putting to perceive that you are “telling them what to do.” If symptoms are higher than the week before, inquire as to why this is the case. If symptoms are lower, you can point to whatever skills the client tried and see if using the skills seems to have contributed to the improvement.

Potential Pitfall with the Modular Approach Since clients may have areas of difficulty that will not be addressed until future sessions, discuss any potential problems with the approach and plan how you will address such problems. Emphasize the point that

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some of these skills may be familiar to the client. However, they only work if they are continually used. Therefore, for certain modules, the goal may be to start or restart using these skills consistently in order to lay the groundwork for future modules and to lead to more optimal functioning.

Practice Is Highly Important Explain to the client that because ADHD is associated with difficulties with follow-​through, some or all of the skills may seem difficult at first. This is the reason for doing the work both with a therapist and by oneself. As a consequence, regular review and practice of skills will occur in the session itself, as well as outside the session during the week. Although these skills may seem difficult at first, with practice they become much easier and eventually become “second nature.”

Ask About Potential Problems with the Treatment Itself Some difficulties with following the treatment program include attendance, attention, and adherence to the treatment. These problems are part of the diagnosis of ADHD itself and can potentially interfere with the treatment. Convey that when difficulties with follow-​through with the therapy itself arise, it is important to discuss these difficulties instead of missing a session. Also convey that we realize that difficulties with follow-​through can be part of the disorder itself. Discuss the importance of attending all sessions in order to achieve benefit. Research on most cognitive behavioral interventions suggests that the more effort a person puts into a treatment in terms of completing homework and attending sessions, the more the person will benefit.

Discuss a Plan for Refocusing When You Think the Session May Be Going Off Topic One potential difficulty can include staying on topic and sustaining attention. Therefore, you will need to aid in refocusing if and when

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the topic of importance is no longer the focus of attention in the session. Discuss this upfront with clients so that they can agree with this plan and not take this refocusing personally. Some potential aids may include:

Asking the client to give you permission to utilize a hand signal when it’s time to refocus. ■ Saying to the client, “This is one of those times where I am now going to interrupt.” ■ Discussing ways that the client can communicate the need to take a break. ■ Reminding the client of how much more time is required and what further topics need addressing. ■

Motivation for Change The next section of this session is dedicated to increasing the client’s motivation for making changes. Some of this material can be repeated on an as-​needed basis as the treatment continues. We provide an illustration of some of the difficulties involved in doing treatment oriented toward behavior change. This metaphor is one used in Dr.  Marsha Linehan’s dialectical behavioral therapy treatment program (DBT; Linehan, 1993). You can talk with the client about negative habits that leave people feeling as if they are stuck in a hole and that the only tool they have available is a shovel (e.g., the negative habit). CBT is like a ladder. If you are only used to working with a shovel, the ladder can feel very strange and difficult to use. However, the ladder is a much more effective tool to use than a shovel to get out of a hole.

Discussion Point: Medications



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Typically, ADHD in adolescence is treated with medications. The goal of therapy is to help clients function at their most optimal level, utilizing medications and the skills from this therapy to help achieve this goal. ■ Discuss the idea that the medications can help a person actually achieve goals of behavioral therapy. ■

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If not already done, discuss the client’s current medications, history with medications, and beliefs about the usefulness of medication. ■ Explain that symptoms of ADHD, such as distractibility or poor organization, may interfere with taking all prescribed doses or may contribute to difficulty in developing a structured routine for taking medication. ■ Discuss the role of parents in medication adherence. In younger adolescents, it may be appropriate for parents to maintain responsibility for medication adherence and remind the adolescent to take medication, schedule doctor’s visits, etc. In older adolescents, especially those who are nearing the time when they will be leaving home to attend college, it may be a goal for the adolescent to take more control over medication adherence. ■ This treatment will help clients who are on medication for ADHD prioritize taking medication and will provide opportunities to work with a therapist and problem-​solve around difficulties taking medications. Each week, factors leading to missed doses will be discussed. ■ If clients are not on medication for ADHD, this does not preclude them from doing this treatment. ■

Task List and Calendar Systems Next, you will introduce the use of the task list and calendar systems. These tools provide the essential foundation for systems that the adolescent will develop throughout the treatment. It is critical that you spend enough time on this section to ensure that the adolescent understands the rationale for these systems and is ready to create their own system. Stress the importance of having a calendar for appointments, school classes, and after-​school sports and clubs, and explain that the rationale for the task list is to record daily and overall goals by importance. As part of this discussion, ask the adolescent about past attempts at using organizational systems. Work with the client to problem-​solve around any difficulties that they experienced. Next, try to come up with the best organizational system for the client to start or start using again. The organizational system must have a calendar and a task list. The discussion should focus on finding a single system that is feasible for the client to start using. Some clients spend 31

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so much time trying out new systems that they never have a chance to make one system work. There is no perfect system. Encourage clients to choose one and commit to using it for 3 months. At that time, they may make a change if needed. Many systems are available for use on smartphones, tablets, computers, and laptops. We will not list specific brands or apps in this book as the specific systems change and new options are always becoming available. The first goal is for the client to have a way of keeping track of classes, appointments, and activities so that one look at the calendar for the day, week, or month will reveal everything that the adolescent needs to do. Family members may need to be involved in developing the calendar system, as parents or other family members need to be made aware of commitments. For example, parents may need to drive teens to sports practices, play rehearsals, or medical appointments. The second goal is for the adolescent to have a single system for keeping track of tasks and to minimize the fear that there are unknown tasks to be addressed. If the adolescent does not already have a workable calendar and task list system, creating such a system is the principal home practice assignment for the next session. Remind the adolescent to bring a way of looking at the system to every session as it will be used in most sessions. From this point forward, the client should put all classes, appointments, practices, club meetings, etc. in the calendar. If using an electronic system, the client should enter the appointment at the time it is made and should also set a reminder for the appointment as it is being entered. You may need to discuss and problem-​solve around any concerns a client may have about this. We often hear clients discuss reluctance to make others wait while the client enters an appointment or finds their calendar to discuss a meeting date. Assist clients in identifying and problem-​solving around these concerns. Discuss the issue of using a paper planner versus an electronic system. Although adolescents generally have electronic devices (phones, tablets, laptops), sometimes they are not allowed to use them in school or at other times when they might need to input appointments or assignments into their systems. Also, there are many other distractions on these devices, such as multiple apps, access to the internet, and so on. Adolescents are sometimes ambivalent about using electronic systems for these reasons.

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Often adolescents will say that they already have some type of a paper planner that is provided by their school, but they are not using it consistently. Barriers to using the planner can be discussed at this juncture. Sometimes it is simply a matter of getting into the habit of using the planner consistently, but in other cases the planner does not meet the needs of the adolescent and alternative systems should be considered. We try to individualize recommendations based on the needs of each adolescent, but we have generally found that planners that are small enough to be carried in a purse or backpack yet have ample room to write in assignments, work best. Generally, planners that have a full page per day on the weekdays allow enough space to write homework assignments and other tasks. If adolescents are trying to fit a lot of information into a small square (such as in a planner with only a small square of space for each day), details can be missed. You can assist the adolescent in coming up with a workable system. The adolescent should also begin a master task list. Any task that must be completed should be written in this list. The idea is to eliminate the use of all alternate systems (like sticky notes, multiple lists on paper, or notes stored electronically). The adolescent should look at the task list every day. Home skills practice this week includes finding all appointments and tasks that may have been recorded in other places and entering them into the master system. All other papers should be discarded. In the first parent/​adolescent session (see Chapter 2), a reward system will be developed. Use of these systems can be targeted as a goal for behavioral change for which the adolescent can be rewarded. This will help to encourage the development and use of these skills. Involvement of Parents During Treatment Over the next several months, the adolescent will be working to develop new skills and habits for managing ADHD. In our experience, having the support and involvement of one or both parents can be extremely helpful. Such involvement provides an opportunity for the parents to learn more about ADHD and teaches them the skills that are taught in CBT for ADHD. It also enables the client and their parents to discuss how ADHD has impacted their relationship. Finally, it enables the client

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to enlist the support of another person or people to aid with homework, problem-​solve with difficulties in the household related to ADHD, etc.

Potential Pitfalls Adolescents may be reluctant to make significant changes that will decrease the impact of ADHD on their lives. They may feel overwhelmed, pessimistic about their success, or worried about having time to practice skills at home. It can be helpful to emphasize that you will be guiding them to make changes gradually and that you will work together to make the new skills feel manageable. It is certainly inevitable that new behaviors will feel different, perhaps uncomfortable, at first and may not lead to success immediately. Sometimes thinking about change in terms of an experiment can be helpful. We suggest that you encourage clients to try new strategies for several months, to give them a real chance of becoming more familiar and automatic. In the end, clients can always go back to their old ways, but we fully believe that they will have success with this treatment. It can also be helpful to emphasize the potential benefit of making small changes. Looking at a calendar each day may only take 3 minutes but can have a tremendous pay off when organization is improved and productivity increases. Therapist Note: Parents should be informed that they will be included for the full session at the following visit, and this session should be scheduled.

Practice The adolescent should:

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Create an organizational system with a calendar and a task list following the preceding guidelines. ■ Put all appointments in the calendar and start one master task list. ■ Read over the materials for the next session. ■

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CASE VIGNETTE All chapters in the Therapist Guide will conclude with a vignette in which the Therapist, Client, and Parent (if applicable) illustrate a key point of the chapter. Therapist: I’ve now given you an overview of CBT for ADHD. What do you imagine might be some difficulties you may have with the treatment? Client: Well, in theory it all sounds good, but I just don’t see how it will help me. I already know this stuff, but it doesn’t work. Therapist: Why do you think it doesn’t work? Client: I can stick with it for a week or two, and then I just forget about it and do stuff the way I used to do it. Therapist: I see. You feel that you won’t stick with it, and then it won’t be helpful. Client: Yes. Therapist: May I share some of my experience on this topic? Client: Ok. Therapist: For most people, change is hard, and change takes time. With ADHD, it can be especially difficult to stay motivated long enough to let the skills sink in and really work. Has that been the case for you? Client: Yes. Therapist: Ok, well this treatment was designed with that in mind. You will not be alone in this! I will be working very closely with you to help you stay motivated. Also, how would it be if we present the material so that all the skills are broken down into very manageable sections, so you will learn one piece at a time? Client: That might help. Therapist: What we have also found to be helpful is that you and I will review these skills over and over, so it will really help them become more familiar. In the end, it won’t take as much effort; these skills will be automatic. How does this sound? Client: Well, I guess I can try it. Therapist: Wonderful. And that is a key point here. We only want you to do skills that actually help. If we find that one strategy

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does not work after you have tried it for enough time, you do not have to do it anymore. Client: I guess I need to do something different so I’ll try. Therapist: Exactly! I really believe you will benefit from this treatment. It gets easier as you go along.

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CHAPTER 2

Session 2: How Can Parents Help? First Parent/​Adolescent Session

Therapist Note: This session can take place any time between sessions 2 and 4. The primary goals are to provide the parents with information about the treatment and to make sure they are going to be supportive of the client. You can use your clinical judgment and also work around the schedules of your client’s parents in deciding when to schedule this session.

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist

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Session Outline

Set agenda Review ADHD symptom checklist ■ Provide education about ADHD from the Introduction and Session 1 ■ Provide overview of the cognitive behavioral therapy (CBT) model of ADHD ■ Solicit feedback from the parent(s) on the adolescent’s symptom severity ■ Discuss the role of parents in client’s treatment ■ Assess parent goals for treatment and manage expectations ■ Develop reward system ■ Agree on home practice activities and anticipate difficulties using these techniques ■ ■

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Set Agenda It is important to begin each session by setting an agenda. Review the session outline with the adolescent and parents. It may be helpful to review the rationale for agenda setting with the parents. Explain that you will be setting an agenda so that everyone will know what to expect in the session and to ensure that you remain focused on helping the adolescent and parents learn more about managing ADHD. You will also address ways in which ADHD may impact family relationships and discuss ways that parents can be helpful in facilitating use of skills. It is helpful to acknowledge that you won’t be doing “family therapy,” but you will be trying to help the adolescent and their parents work together to come up with systems to help the adolescent manage their ADHD symptoms.

Therapist Note:  See the “Potential Difficulties” section later in this chapter. It is common that many parents have been frustrated and “fed up” with their children with ADHD for a long time due to symptoms of the disorder. When conducting this session, it is important to (1) be realistic about progress, (2) avoid having it become a session about how awful it has been for the parents, and (3) work on positive steps to try to alleviate symptoms. Generally, the idea is to work with the family to try to reduce the degree to which parent involvement is seen as “nagging” and come up with an agreement about how the parents can support the adolescent in a way that the adolescent perceives as being helpful. This can be something that is difficult to achieve in just a few sessions.

Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference. Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent 38

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about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​__​_​_​_​_​_​

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Review of Material from Session 1 The goal of this portion of the session is to provide the parents with the educational information that was presented in the previous session. Realistically, there will not be enough time to cover the material in its entirety. Review the sections that dispel myths about ADHD and introduce the CBT model of ADHD. Finally, discuss some of the techniques that will be utilized during treatment, such as the task list and calendar systems. In addition, it is important to discuss the role of home practice in the adolescent’s success with the treatment. This may be a critical area in which the parents can provide encouragement throughout the program. Monitoring Progress Ask the parents to also complete the ADHD symptom checklist as a secondary way to report on progress. If the parents and adolescent are 39

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willing, instruct each parent to complete the symptom checklist on their own and then compare ratings with each other and with the adolescent to see if problematic areas are similar.

Discuss the Role of Parents During Treatment ADHD can create stress for both the adolescent who has ADHD and for the parents and siblings who care about and live with the client. Ask the adolescent and parent(s) to describe problems that the ADHD has caused for the adolescent and also for the family. This is an opportunity to gain a better understanding of the issues that the adolescent and their family are currently facing. Without explicitly asking, it is also an opportunity for you to gauge the level of frustration that the parent(s) are currently experiencing. This information will prove helpful in decision making regarding the level of involvement that you are asking the parents to have with regards to the home practice assignments. With adolescent clients, parent involvement is important. However, if parents are feeling very frustrated and burned out from dealing with their child’s problems, it may be advisable to have them play a more limited role in the therapy. If, on the other hand, the parents seem to have a strong relationship with the adolescent and display patience toward their child’s difficulties, they may prove helpful in coaching the adolescent to implement skills at home and at school. Having the support of a family member can enhance the client’s success in CBT. Parents can remind clients to practice skills at home each day, can assist in identifying locations for storing important items (from the Distractibility module presented in Sessions 6 and 7 of this Therapist Guide), and can provide general support and encouragement. They can also be instrumental in providing financial support for the adolescent (e.g., in paying for tutoring and buying organizational supplies or apps). It is important that the adolescent and parents agree on acceptable ways of providing support. For example, it may not be effective for a parent to nag the client multiple times a day about practicing skills. However, the adolescent may feel that a gentle daily reminder would be helpful. It may be useful to have a discussion with the parents about the difficulties of finding the balance between parenting the adolescent with ADHD and letting the adolescent with ADHD do things independently (running 40

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the risk that tasks might not get completed, etc.). Similarly, it is important that parents are “on the same page” when it comes to scheduling and prioritizing tasks and appointments. In this session, the adolescent and parents can agree on a regular time for a weekly meeting when such things can be discussed. The family can also discuss things such as synching their calendars with one another and sending each other electronic invitations to events so that they will be aware of the time commitments of all family members. This discussion will differ depending on the developmental level and age of the adolescent. For example, parents are going to be much more involved in scheduling, etc. in younger adolescents because they will need to drive carpools and pay for lessons, while older adolescents may be able to get themselves to appointments, lessons, and practices. Parents may be more tolerant of letting older adolescents do things on their own, although sometimes they may perceive a risk that they are not willing to tolerate (e.g., an adolescent who is a junior in high school not studying for standardized tests and not doing well in the college admission process), which might push the parents to become more involved in managing the adolescent.

Potential Difficulties In many cases, the parents are highly frustrated with the adolescent for reasons related to ADHD. We have had many parents who communicate frustration with and anger toward their adolescents with ADHD. As a therapist, it will be your job to strike the balance of eliciting the help of the parents for positive social support but not continued negative social interactions (i.e., nagging) that might make it more difficult for the adolescent to achieve their goals.

Preview Treatment Modules To enlist the support of the parents and to continue to instill credibility and confidence in the treatment, it can be useful to preview the treatment modules and discuss with the parents how they can relate to 41

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the effect of ADHD on family relationships. Explain each module and brainstorm ways that parents can help.

1. Organization and Planning The central goal of this first set of sessions (Chapters 1–​5) is to develop a comprehensive system for organizing and planning. This means consistently using a calendar and task list system (looking at the task list and calendar daily), learning problem-​solving skills, and managing organization. Areas in which the parents can help include:



Assuring that important family events get put into the calendar ■ Assisting with prioritization of tasks, and, if a mutually agreed on important task arises, making sure that it gets put onto the task list ■ Helping the adolescent find a place for important items (backpack, laptop, homework, cell phone), and if these items are seen elsewhere, moving them back to the designated place or alerting the adolescent to the fact that they are out of place ■ Helping the adolescent purchase items they need for their organizational systems ■ Providing positive feedback ■

2. Coping with Distractibility The central goal of this set of sessions (Chapters 6–​7) is to learn tools for coping with distractibility. This entails learning about the length of one’s attention span and breaking down tasks into steps that take that amount of time. It also involves skills like “distractibility delay” and modifying one’s environment to so that work can be done efficiently.

3. Adaptive Thinking The central goal of this set of sessions (Chapters 8–​10) is to learn to think more adaptively about situations or tasks. This involves learning to identify one’s thoughts, looking at the relationship between

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thoughts and mood, identifying evidence for or against the thought, and then developing an alternate way of thinking about the situation or task.

Assess Parent Goals for Treatment and Manage Expectations Talk with the parents about their goals for treatment and ask them to complete Worksheet 1: Goals of Cognitive Behavioral Therapy (CBT)-​ Parent Version, located in the Appendix. Therapist Note:  If you or your clients require additional copies of any of the worksheets, you can download blank copies from the Treatments ThatWork website at www.oup.com/adolescentADHD It is important to make sure that the goals the parents have for the program are realistic. For example, if the child is entering treatment in January and already has poor grades for the first half of the school year, the goal for the adolescent to have all A’s for the school year is not realistic. At this juncture, the adolescent can share the goals that they set in session 1 (see their completed copy of Worksheet 1) with the parents. Compare the two sets of goals (on Worksheet 1 completed by the adolescent and Worksheet 1 [Parent Version] completed by the parent) and highlight and discuss any similarities or differences to make sure that all parties are on the same page. The goals should be written out and saved in the adolescent’s chart. These goals will be reviewed at the second parent session, later in the treatment program. In this session, it is helpful for you to gain an understanding of what the parents expect from the adolescent at home (rules, chores, homework, etc.) as well as the current rules around task completion (e.g., does the adolescent earn access to preferred activities if they complete homework or chores?). Finally, it is important for you to convey the message that we are all aligning against the ADHD:  parent(s), adolescent, and therapist are trying to figure out the best way to combat the difficulties caused by ADHD.

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Positive Versus Negative Support “Nagging” and other excessive negative support can actually make the problems worse in that they can instill a sense of hopelessness and helplessness in the adolescent. The goal of parent involvement is to help the adolescent learn independence and compensatory skills that they previously did not have. This is a gradual process and, per our cognitive model, can be negatively impacted through excessive focus on past failure experiences. A focus on building on past successes to learn new skills is more likely to be effective.

Develop Reward System At this juncture, discuss the issue of a contingency management or reward system with the adolescent and parents. It is important to emphasize that the goal of the reward system is not for the parents to “bribe” the adolescent, but rather to indicate an appreciation of the fact that changing one’s behavior is very difficult and that a reward system can increase motivation to do the hard work that is needed. The reward system should be developed collaboratively with both the adolescent and the parents. The behaviors that the parents are rewarding should be clearly specified. Rather than rewarding “good grades” (which is a longer term outcome and is dependent on many different variables), a better behavioral target might be “writing down homework assignments in planner every day.” It is helpful to reward attempts to use new skills, even if the outcome isn’t always 100% successful. The adolescent needs to develop new habits that will lead to success over time, but if early efforts are not rewarded, the adolescent is more likely to become discouraged and may not continue using the systems long enough for them to become habits. For a reward to be effective, it should be something that the adolescent does not normally have access to (a privilege, an activity, or a tangible item). For example, if a teen normally has access to video games at all

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times, extra video game time would not really feel like a reward. The rewards will look different depending on the age of the adolescent, and parents will need to be more involved in managing the system with younger adolescents. Younger adolescents might opt for rewards such as going out to dinner at a favorite restaurant, going to a movie or an amusement park with a friend, getting a new video game, or spending one-​on-​one time with a parent. Older adolescents might opt for extra privileges or gift cards to favorite stores, movie theaters, etc. The reward system should not be too complex and difficult to administer. All too often, families work out complex reward systems, use them for a short period of time, and then stop using them because it becomes too difficult to keep track of points earned and rewards redeemed. Even the most well-​designed reward systems are not going to be effective if they are not used consistently!

Potential Pitfalls A common concern among therapists is that the adolescent will feel victimized and attacked when problematic symptoms are identified. You should set the stage for a constructive session by acknowledging that ADHD does not mean that a person is lazy, stupid, or weak. Rather, individuals with ADHD must use skills and strategies to cope with symptoms effectively. In addition, you should control the session and not allow the parents to rant about frustrations with the adolescent. This session is an opportunity for parents to receive education about ADHD and CBT and for the parents to collaborate with each other to identify strategies for providing support for the adolescent during treatment.

Practice

The adolescent and parents should continue to discuss ways in which the parents can provide support while the adolescent is in treatment. ■ The adolescent should read over the materials for the next session. ■

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CASE VIGNETTE Therapist: We have now reviewed the educational materials on ADHD and discussed the outline of CBT treatment. Let’s spend some time thinking about how your parents can support you during treatment. [Client], what kind of support do you think will be most helpful for you? Client: I think finding time to practice my skills at home. I have so much to do between my part-​time job, my homework for school, and my chores. I’m lucky if I  can get  all that stuff done. I’m totally stressed out all the time! Parent: Maybe we can think of a task that I could do for you so you have a little more time to work on CBT skills at home. Therapist: That is a great idea! We don’t want you to feel too burdened, but if there is one task you could be responsible for during this 12-​week treatment, that would be helpful. [Client], what do you think? Client: I feel badly that my mom would be doing more work than she already does. I guess I would want to make sure she was really ok doing that. Parent: You can trust me on this, but if there are days when I need some extra help, I promise I will let you know. Therapist: So what would be the task to hand over to your mom? Client: I think the best time for me to do homework is first thing in the morning. If my mom could make breakfast, it would give me 15 extra minutes. Would that be ok? Parent: I could definitely try that out. Therapist: I think what you’ll find is that if [Client] takes those 15 minutes in the morning, he will actually be more organized and productive during the day, which will help out mom as well in the end. Client: That’s true. Parent: Yes. Therapist: This is a great start! Keep in mind that you can revise your strategies. Sit down in a few weeks and check in with each other to see how things are going. Ask if either one of you feels more burdened. With communication, these challenges can be addressed. Good luck! 46

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CHAPTER 3

Session 3: Do The Most Important Things First!

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 2: Task List, located in the Appendix ■

Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review adolescent’s use of the calendar and task list systems ■ Teach adolescent how to manage multiple tasks ■ Teach adolescent how to prioritize tasks ■ Problem-​solve regarding any anticipated difficulties using these skills ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda.

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Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.

Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​____​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Signposts of Change

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In this section, we will highlight the client behaviors that serve as indicators that the therapy is on track and progressing well. If your client

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is not exhibiting these behaviors, discuss and conduct problem-​solving to uncover any obstacles that might be preventing the client from using the skills. For this session, the signposts of change are:

Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■

Review of Previous Sessions As always, this session includes a review of the client’s progress in implementing skills from each of the previous sessions. Review the client’s progress in implementing skills from Sessions 1 and 2. It is important to acknowledge the successes the client has achieved and to problem-​solve around any difficulties. The client should be putting appointments in their calendar on a regular basis and have a master task list on which they put all tasks that need to be completed. It is not necessary that this system work perfectly at this stage, but it is important for the client to be attempting to use the systems consistently. It is also a positive sign if the client has identified a consistent time and place to select tasks for the day and plan how the tasks will be completed. If the client has not yet started using a calendar and task list system, conduct problem-​solving around this issue because the client cannot effectively proceed with the treatment until these systems are in place.

Review: Tools for Organization and Planning



Use of calendar for managing appointments: At this point, you should discuss any problems that the client is having with using their calendar system ■ Use of task list system: Review any difficulties that the client is having with writing down and using their task list on a daily basis ■

Remind the client that having a good calendar and task list system is necessary (but not sufficient) to getting organized. 49

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If the client has started these systems, review the specifics:

Where will the client keep the calendar and task list? How will the client remember to look at the calendar and task list every day? The client should pick a time or activity that already occurs every day to link with looking at the calendar and task list (e.g., having morning coffee, brushing teeth). Stress the importance of looking at both the calendar and the task list every day. Also inquire about additional steps to communicate with others (e.g., sharing information about scheduled events/​commitments with parents in order to facilitate rides).

■ ■

Managing Multiple Tasks We often need to manage multiple tasks at one time. Individuals with ADHD can find it extremely difficult to decide which task is most important. Even once they have decided that a particular task is important, it is often difficult for them to stick with it until it is completed. Other less important tasks can become distracters (i.e., texting friends, playing video games, going online) and the critical task gets overlooked. The following exercise teaches clients a concrete strategy to decide which tasks are most important. This technique is one example of how individuals can “force themselves” to organize tasks even though it is difficult for people with ADHD to process this type of information. It can be helpful to ask the client how they feel about being more strategic in approaching the day. Some clients discuss wanting freedom for creativity or inspiration or that they feel stifled by the restrictions of a list. You can help assess the pros and cons of an organized versus unorganized day with regard to productivity, personal satisfaction, and relationship cohesion.

Master List Versus Daily List It is important for clients to have both a “master list” that holds all of the tasks that they need to complete in general, as well as a “daily list” of tasks that the client is actually hoping to complete on a particular day.

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The client can divide the list up into different sections, such as homework and college applications or other personal tasks, if desired. You can use Worksheet 2: Task List (in the Appendix) to help your client create a task list. This format can be used for either a master list or a daily list. Your client can also use a different format or an electronic system. All tasks should remain on the master list until they have been completed. If a task on the daily list does not get completed that day, it should be moved to the next day’s list. Many electronic systems allow items to be assigned a particular date, and the item will automatically move to the following day if it has not been checked off as having been completed. This can also be done using a paper system.

Skill: Prioritizing When clients are faced with a number of tasks that must be completed, it is important to have a clear strategy for prioritizing which tasks are most important so that the most important tasks get completed. A useful strategy is to develop a system for assigning a priority rating to each task. Prioritization can be used on the master list to help indicate which items ought to be moved to the daily task lists (because these items are important and need to be attended to right away), and it can also be used within the daily list to help clients decide how to put the daily tasks in order of importance. Talk with clients about the fact that people often like to start with completing those tasks that are easier but less important. This gives the impression of getting things accomplished, but one never makes progress toward important goals. So it seems to work in the short term but actually does not work in the long term. By adding “A,” “B,” and “C” ratings to the task list, clients can address this issue. Instruct clients that it works best to list all of the tasks first and then assign the priority ratings.

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Skill: The “A, B, Cs”

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“A” Tasks: These are the tasks of highest importance. This means that they must be completed in the short term (like today or tomorrow).



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“B” Tasks: These tasks are lower importance, longer term tasks, some portions of which should be completed in the short term, but the other portions may take longer. “C” Tasks:  These are the lowest importance tasks; they may be more attractive and easier to do, but they are not as important.

A goal of this session is to help the client generate a task list and then assign a rating of “A,” “B,” or “C” to each item. Pay attention to how many items are being assigned to each category. Clients may tend to assign all items an “A” rating, thus making the strategy less useful. Only 3–​4 items should have an “A” assignment at a given time. “A” list items may be transferred to a daily list either on a separate piece of paper or on the daily calendar. In this way, the client will not be distracted and overwhelmed by the entire list; only the “A” list items need to be viewed. Younger adolescents may simply wish to put their tasks/​assignments in order of importance and then work down the list, one assignment at a time. Older adolescents may have more varied tasks that they are juggling: for example, completing a problem set for math class, writing an outline for a paper, doing an hour of standardized test prep, and working on a college application essay. The “A,” “B,” “C” rating system works well with varied tasks because the adolescents need to stop and think about not only what is an immediate task that needs to be completed, but also what is going to be helpful to achieve longer term goals (e.g., getting into a top-​choice college). Talk with the adolescent about making sure that all “A” items are completed before moving on to the “B” items and making sure that all “B” items are completed before moving on to the “C” items. Emphasize the importance of sticking to this rule if the strategy is to be effective. Talk with the adolescent about how using this strategy can help reduce procrastination: if the higher priority, yet 52

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more challenging, tasks get put off, this can increase stress. If the adolescent is following their priority ratings, this will ensure that they are at least doing one chunk of the high-​priority tasks each day. Tell the client to use this technique every day. If using a paper system, they should copy over the “to-​do” list when the old one becomes too messy.

Skill: Use of Rewards to Increase Motivation Talk with the client about what motivates them and how it can be used to aid in task completion. For example, you can discuss the Premack Principle, which says that a low-​frequency behavior will increase in frequency if it is made contingent on a high-​frequency behavior. Discuss this with the adolescent (e.g., “How do you end up spending your time?”, “What things do you like to do?”). You can then discuss how the adolescent might use this information to help them complete tasks, such as homework or chores, that are less interesting or fun. For example, the adolescent might try setting up an “if  .  .  .  then” rule such as, “If I  finish this history reading assignment—​pages 55–​67—​then I  can watch some videos or an episode of a show.” Encourage the client to be specific about both the to-​be-​accomplished task and the rewarding activity. In this session, you can also discuss the reward system discussed at the parent-​adolescent session. Emphasize that we are not suggesting that parents “bribe” the adolescents to do homework, etc., but rather that parents should try to help increase motivation to do something that the adolescent is having a hard time doing. You can use a personal example (e.g., “When I have a lot of paperwork to do at work, I might tell myself that I can get a manicure after work if I get it all done”). You can talk with the parent about the reward system at the parent check-​in.

Potential Pitfalls The client may become discouraged or feel overwhelmed when trying to learn these new strategies. These strategies serve as an investment in the future, and, like a monetary investment, it takes effort to set aside other 53

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agendas to invest in the future. Also remind the client that new behaviors become comfortable with repetition. Talk with them about the fact that it takes time to change long-​standing habits, and review the benefits of becoming more organized and more effective at completing long-​term goals. Problem-​solve with the client about any specific difficulties that they may be encountering. Practice The adolescent should:



Put all appointments, meetings, practices, and other commitments in the calendar and review the task list on a daily basis. ■ Use and look at task list and calendar every day! ■ Select items from the master list to put on the daily task list. ■ Rate each task as an “A,” “B,” or “C” task or assign numbers to tasks. ■ Practice doing all of the “A” tasks before the “B” tasks and all of the “B” tasks before the “C” tasks, or doing tasks in the order that the client set at the beginning of the day. ■ Carry over tasks that are not completed from the previous day to the next day’s list. ■

CASE VIGNETTE Therapist: Would it be ok if we take a look at your task list? Client: Ok, sure. Therapist: Thanks. I see that you have three things on your list for today. Why don’t we try to figure out if each item should be rated as an “A,” “B,” or “C” task. Client: This is going to be difficult. Therapist: Yes, it can be. That is why I am here. So, let’s just take one item at a time. The first one is “start English paper.” What rating should we give that one?

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Client: I have a C in English and my parents are upset about it. I’m normally pretty good in English, but I haven’t been working too hard this term. Therapist: Ok. Let’s assign that an “A” rating. How about the next one, “make poster for car wash to raise money for new cheer uniforms”? Client: Well, I do need to do it, but the car wash isn’t for a couple of weeks, so I probably don’t really need to do it today. I really like creating things like that on the computer though, and it would only take a few minutes to do it. Therapist: How would you feel if we made that one a “C”? Client: Why a “C”? Therapist: Well, using this approach, we would consider this the type of task that people often want to complete because it is enjoyable and straightforward. The problem is that you can get so busy with these small tasks that the more important ones never get completed. How about if you try to complete this one after you have completed the more important “A” and “B” tasks? Client: Sure. That makes sense. Therapist: The third item is, “do homework for ACT tutor.” What rating should we give that one? Client: Well, I am taking the ACT next month. My tutor gives me tons of homework to do each week, and I feel like I can never get it all done. Therapist: It sounds like an important task, but maybe it is too large to tackle all at once. Can you think of a way to break off a smaller piece of the task? Client: Maybe just doing one section and reviewing the answers today? Therapist: Ok. Let’s rewrite this as “take one section of a practice ACT test” and rate that one as an “A.” Client: Sounds good.

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CHAPTER 4

Session 4: What to Do When Things Aren’t Getting Done: Breaking Down Tasks and Problem-Solving

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 3: Problem-​Solving: Selection of Action Plan ■ Worksheet 4: Problem-​Solving: Pick Three ■ Worksheet 5: Problem-​Solving: Small Steps, all located in the Appendix ■

Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review adolescent’s use of the calendar, task list, and “A,” “B,” “C” priority ratings ■ Teach adolescent to use problem-​solving to overcome difficulties with task completion and selection of a solution to a problem ■ Teach adolescent how to break down a large task into small, manageable steps ■ Problem-​solve regarding any anticipated difficulties using these skills ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for 57

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what lies ahead in the upcoming session. Use the preceding session outline to set the agenda.

Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.

Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​ needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Signposts of Change For this session, the signposts of change are:

Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■

Review of Previous Sessions As always, this session includes a review of the client’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties. It is critical that the client start implementing the use of the calendar and task list systems, if not already done. Individuals with ADHD may postpone starting to use a system because they are searching for the perfect system. Using a calendar and task list, however, are building blocks for all the sessions to come. It is important to encourage the client to make a decision and pick a calendar system and a task list system—​despite the fact that they may not be the most cost-​effective option, the very best option, etc. You can validate that it is often tempting to keep looking for a better system and note that this search can interfere with approaching the tasks on the task list that need to be completed and starting to get things done.

Review: Tools for Organization and Planning

Use of calendar for managing appointments ■ Use of task list system ■ Use of the “A,” “B,” and “C” priority ratings ■

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Problem-​Solving Strategies This section involves helping the adolescent learn to recognize when they are having difficulty completing a task or are becoming overwhelmed and cannot figure out exactly where to start. Explain that this situation can lead to procrastination and other problems. One way to figure out where the following skills should be applied is to look at the adolescent’s task list. If there are tasks that have been on the task list for many days, weeks, or months and have not yet been started (e.g., the adolescent is aware that the task needs to be done but is procrastinating starting, working on, or completing the task), the following strategies should be considered. You will be teaching two key skills: 1. Selecting an action plan, and 2. Breaking down an overwhelming task into manageable steps. Worksheet 3: Problem-​Solving: Selection of Action Plan (or Worksheet 4: Problem-​Solving: Pick Three, for younger adolescents) will be used to select an action plan. Explain to the client that developing an action plan can be helpful when it is difficult to determine how to resolve a problem or when the possibility of numerous solutions becomes overwhelming. Selecting an action plan involves the five steps in problem-​solving listed here.

Skill: 5 Steps in Problem-​Solving Use these instructions in conjunction with Worksheet 3. Worksheet 3 is similar to the one we use with adult clients and is appropriate for older adolescents. Younger adolescents may find this worksheet to be too complex, so Worksheet 4 (Pick Three) can be used instead. When teaching these steps, it is important that you emphasize to the client that the goal of this exercise is for them to learn a strategy called “problem-​solving.” Although we are looking for a specific example here, and you are going to help with that specific example, the goal is for the client to take this skill and the steps described here and apply them to other problems that come up in the future.

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1. Articulate the problem: Try to get the adolescent to describe the problem in as few words as possible—​one to two sentences at the most. Examples might be “I cannot decide whether I should switch out of my AP English class,” “I cannot decide if I should take a gap year after I  graduate from high school.” Note that, in many cases, getting the adolescent to clearly articulate the problem can be the hardest part of the entire process. Clients will tend to mix a variety of problems into one, and your goal here is to help the client articulate one single problem that can be described in a single sentence. 2. List all possible solutions:  In the first column of the chart in Worksheets 3 and 4, the adolescent should try to come up with a number of solutions—​regardless of how possible they are, what the consequences may be, or whether or not they sound outrageous. The idea is really to generate a list of as many solutions as possible. 3. List the pros and cons of each solution:  Now is the time for the adolescent to realistically appraise each solution. In the next columns, the client should figure out what they really think would happen if they selected that solution. The pros (advantages) and cons (disadvantages) of each should be listed. 4. Rate each solution: Using the final column, the adolescent should rate the pros and cons of the solution on a scale from 1 to 10 (with 1 being a terrible solution and 10 being the best possible solution). This should be done as objectively as possible. 5. Implement the best option (see next skill of breaking down a problem into manageable steps):  Now that the adolescent has rated each option on a scale of 1–​10, each rating should be reviewed. Look at the one that is rated the highest. Determine if this is really the solution that the client would like to pick. If so, help the client use the other skills learned in this treatment program (problem-​ solving, organizing, task list, calendar) to implement it.

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Skill: Breaking Down Large Tasks into Manageable Steps Explain to the adolescent that by learning how to break large tasks down into smaller, more manageable, steps, they will increase the likelihood of starting (and therefore eventually completing) important tasks. Each task on the task list should feel absolutely doable in one day. If it doesn’t, break it down into a smaller task. How to Break Down Large Tasks into Manageable Steps: 1. Choose a difficult or complex task from the “to do” list (or the solution you identified on Worksheet 3 or 4, earlier in this session). 2. List the steps that must be completed. This can be done on a piece of paper, a white board, or a note app on a phone or other electronic device. You should ask questions such as, “What is the first thing that you would need to do to make this happen?” “What is next?” 3. For each step, make sure that it is manageable. Have the client ask themselves, “Is this something that I could realistically complete in one day?” and “Is this something that I would want to put off doing?” If the step itself is overwhelming, then that step should be broken down into smaller steps. 4. Add each individual step to the master list. 5. Individual steps can be moved to the daily task lists one at a time as needed. 6. Individual tasks can be placed on the client’s calendar in specific time slots if they find this helpful. Present the adolescent with Worksheet 5:  Problem-​Solving:  Small Steps and talk about how it can be used to break a large task down into smaller steps to make it more likely that the task will be completed.

Potential Pitfalls Adolescents with ADHD may find that their distractibility interferes with their ability to use these skills. Reassure them that they will be learning additional skills to deal with distractibility in future sessions. 62

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Emphasize the importance of focusing on one set of skills at a time in order to make progress. Also, clients may report difficulty with rating the pros, cons, and overall desirability of solutions. Again, reiterate that this is a new skill that will take lots of practice until it feels comfortable for them. Again, a big potential pitfall has to do with implementing a calendar and task list system. If, by now, your client has not been able to find a good system, encourage them to start using one immediately after the session (and/​or you can use the next session to start setting up systems with the client using what they have available at the time). To help the client get into the habit of using the calendar system, it may be helpful for the two of you to “rehearse” the scenario, using imagery. For example, ask the adolescent to imagine looking at their calendar and ask: “What time is it?” “Where will you be sitting?” “What will be in front of you?” “Will it be silent or will you have music playing?” It may also be useful to troubleshoot barriers to home practice completion. Ask the client: “What is most likely to get in your way of sitting down to do this?” “What thought might go through your head (e.g., ‘I can do this in a half hour’) that might derail completion of the home practice?”

Practice The adolescent should:



Continue to put all appointments in the calendar. ■ Put all tasks on the master task list. ■ Use and look at the task list and calendar every day! ■ Use priority ratings. ■ Practice doing tasks according to the priority ratings. ■ Carry over tasks that are not completed to the next day’s daily task list. ■ Practice using Worksheet 3:  Problem-​ Solving:  Selection of Action Plan or Worksheet 4:  Problem-​Solving:  Pick Three for at least one item on the task list. ■ Practice breaking down one large task from the task list into smaller steps using Worksheet 5: Problem-​Solving—​Small Steps. ■

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CASE VIGNETTE Therapist: Would it be ok if we look at your task list and see if there is anything that needs to be broken down into smaller steps? Client: Ok. How about this one, “organize my friend’s surprise birthday party”? Therapist: Fun! That sounds like a good one. What are the steps that you need to take to do that? Client: I need to decide where I want to have it. Therapist: What would some other steps be? Client: I need to text the friend whose house it will be at and make sure that he is ok with the plan. Therapist: Sounds good. Then what do you need to do? Client: I need to decide who to invite. Therapist: How are you going to let the guests know about the party? Client: I’ll text them. Therapist: Ok, this is great—​you are breaking the overwhelming task into steps. Why don’t you go ahead and put each of those steps down as separate items on your list. Can you think of any other things that you need to do? Client: Maybe get a cake and buy my friend a present. Therapist: You can put each of those down on your list as well. Client: Now I have a long list of things to do. What do I do next? Therapist: You can take that list and move things onto your daily task list. So, what do you want to do from that list tomorrow? Client: I guess I should start by deciding where I want to have the party and asking my friend if it is ok. Therapist: Ok, so put those two things down on tomorrow’s task list. What do you want to do the following day? Client: I could decide who to invite. Therapist: Sounds good. Do you think you can finish this process on your own this week? Client: Yes. I feel like I can do it a little bit at a time and it will all get done.

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CHAPTER 5

Session 5: How to Organize Everything

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist

■

Session Outline



Set agenda ■ Review ADHD symptom checklist ■ Review adolescent’s use of the calendar; task list; “A,” “B,” “C” priority ratings; problem-​solving; and breaking down large tasks into small steps ■ Assess adolescent’s organizational needs, including school work, backpack, materials needed, and how to get materials to and from school ■ Teach adolescent how to develop organizational systems ■ Problem-​solve regarding any anticipated difficulties using these skills ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the adolescent for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda.

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Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.

Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Signposts of Change For this session, the signposts of change are:

Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I  not really sure how to approach the problem?” Following this, they have either broken down the task into smaller steps or completed a problem-​solving worksheet. ■

Review of Previous Sessions As always, this session includes a review of the adolescent’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties. If the adolescent is not displaying the signposts of change as described, you should take some time to explore what is getting in the way of skills use. Often, individuals realize that they “should” take the time to plan out their days, but then, in the moment, decide that it is more effective to just jump right into doing homework or other tasks rather than “wasting” time planning. You can use Socratic questioning to try to get the adolescent to come around to the view that time spent planning will set them up for a more productive day and will be time well spent.

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Review: Tools for Organization and Planning

Use of calendar for managing appointments ■ Use of task list ■ Use of the “A,” “B,” and “C” priority ratings ■ Use of problem-​ solving (selecting an action plan and breaking down large tasks into small steps) ■

Assessing Client’s Organizational Needs It is important to ascertain where the adolescent is having difficulties with organization. For some adolescents, this may include difficulties with keeping their bedrooms clean, their lockers organized, and backpacks or school notebooks organized. Talk with the adolescent about where these issues are causing difficulties for them; for example, if their parents are getting angry because the client’s bedroom is not clean or the client is missing out on school activities because the notice gets lost in a locker or backpack. Organizational difficulties may arise with electronic files as well. It is possible that the client does not have a good system for naming/​saving files and will have difficulty finding school assignments after spending time working on them. For younger adolescents, parents may need to be involved in this assessment process as they may not be as cognizant of their organizational needs. Older adolescents are likely to be able to articulate the difficulties that their organizational challenges are causing.

Skill: Developing Organizational Systems Another common struggle for adolescents with ADHD is keeping papers, electronic files, and other items organized. Without systems in place, students lose items, leading to frustration when they need these articles or missed deadlines because they can’t find important information. Furthermore, many people find it difficult to throw things away, resulting in a cluttered environment which makes it even more difficult to find important papers or other items. We recommend coming up with systems that are both simple and effective. If systems are too complicated, they are time-​consuming to use and people stop using them. 68

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Ask the adolescent about systems they have used in the past or are currently using. Instruct the adolescent that the filing system should be used for the most important items only. We recommend that anything the client does not critically need should be thrown away. The client’s parents can help to develop decision rules for this. The parents also may need to be brought in to discuss any items that may need to be purchased, such as storage units. Many individuals with ADHD tend to save/​collect items, thinking that these items are something they may need in the future. Review the guidelines in Box 5.1 (which appears both in this Therapist Guide chapter and in the Client Workbook) to help the client develop a system or improve upon a system that is already in place. Box 5.1 Developing an organizational system

1. Decide where you will keep your important things. (Don’t spend too much time making this decision.) 2. Pick one area or container to use. Keep it simple! You only need to keep things here that you will really need. 3. Set up your main files (college applications, high school classes) or categories (school supplies, art supplies). 4. For electronic documents—​sort them into folders. Easiest is one file for each class you are taking, and then additional files for other things. 5. For emails—​also sort these into folders for different classes or activities (for example, one for English class, one for History, and then one for, say, your sports team if your coach emails you, or your drama club if you are in one, and so on). Answer the email and then file it so that you don’t have too many emails in your general inbox. 6. Plan specific times each week when you will use the system. Problem-​solve to make sure that you are not choosing unrealistic times. 7. These tips are general, and it will be important for you and your therapist to discuss and make a plan for your specific needs. 8. Remember that it is important to practice these skills for long enough so that they become a habit. Don’t give up too soon! 69

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Tailor the content of this session to the difficulties that the adolescent and parent describe. If the adolescent or the parent talk about the adolescent having trouble with losing homework, the focus can be on organizing binders, backpack, and locker. If the adolescent describes having a difficult time finding items in their room, or if the parent notes that there is a lot of family conflict over the fact that the adolescent has a messy room, the focus can be on organizing the client’s desk or other areas of their bedroom. If the adolescent loses e-​mail notices or web addresses, the focus can be on developing an organizational system for their computer files. Again, parent input may be needed to fully understand the difficulties that the adolescent’s organizational difficulties are causing for the family.

Potential Pitfalls Clients may think that everything is important. Ask them to discuss this issue with friends and family and come up with a consensus on things that need to be saved. Encourage the client to invest time in the short term to set up these systems. Talk about the value of having these systems in place in the long term. Coach the client regarding breaking down the steps it takes to set up systems into smaller units. Parents will likely need to use rewards to encourage adolescents to develop and use organizational systems. Talk with the client about the utility of discussing their organizational systems with other family members before setting them up. Discuss possible issues with the systems if this step is skipped (e.g., if the parent is still putting papers in a big pile on the chair and the client is trying to use a filing system, the system won’t work very well).

Practice The adolescent should:

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Continue to use the calendar every day to record appointments, practices, rehearsals, and other time commitments and to put homework and other tasks on the task list every day.

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Use and look at the task list and calendar every day! ■ Use priority ratings. ■ Practice doing tasks according to the priority ratings. ■ Carry over tasks that are not completed to the next day’s task list. ■ Practice using Worksheet 3:  Problem-​ Solving:  Selection of Action Plan for at least one item on the task list. ■ Practice breaking down one large task from the task list into smaller steps using Worksheet 5: Problem-​Solving: Small Steps. ■ Set up and use the organizational systems developed in session. ■

CASE VIGNETTE Therapist: So, now I think we should start talking about organizational activities. Would that be okay? Client: Yes. Therapist: Ok, so my first question is this: Where do you have the most trouble organizing your things? Client: I am always losing handouts and homework sheets that my teachers give me. Therapist: That sounds frustrating. Client: Yes, it sure is. Therapist: Ok, but it also is something we can work on. May I ask some more questions about it? Client: Ok. Therapist: Do you know where they get lost? For example, do they end up in your locker, the bottom of your backpack, the floor of your mom’s car? Client: I think it could be any of those places. When the teacher hands stuff out, I  always think that I  will put this paper in a special place, but then when I look for it later, I can’t find it. Therapist: So, it sounds like maybe making an effort to put stuff in a folder or binder right away would make a difference. What type of system do you have for school? Client: I have a binder for each class. Therapist: Would it be possible to put a folder for homework/​ handouts in each binder?

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Client: That would be good. I could just put the papers directly into the binder for each class. Then, later when I go home, I will know where to look for the papers. Therapist: That sounds good. Do you usually have your phone with you in class? Client: Of course! Therapist: You might also take a photo of the worksheet or handout, just to have as a backup. Client: That’s a great idea. That way, even if I lose the actual paper, I know what was on it so that I can still do my homework.

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MODULE 2

How to Keep Going and Not Get Distracted

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CHAPTER 6

Session 6: Gauging the Attention Span and Delaying Distractions

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Clock or stopwatch (phone, tablet, or computer can be used) ■

Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review progress ■ Review use of calendar, task list, and skills from previous module ■ Teach adolescent to gauge their attention span and develop a plan for breaking down tasks into steps that take that length of time ■ Teach adolescent to implement the distractibility delay ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda.

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Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.

Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Signposts of Change For this session, the signposts of change are:



Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken down the task into smaller steps or completed a problem-​solving worksheet. ■ Client has started to implement a system for decreasing the amount of e-​mail and paper that comes in and needs to be dealt with. ■ Client has identified areas that require an organizational system and has started to implement the system as agreed upon with you. ■

Review of Previous Sessions As always, this session includes a review of the client’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties. A common issue that comes up at this point in therapy is that clients are overwhelmed by implementing a new organizational system. It is not uncommon for adolescents to have a huge backlog of school papers, outgrown toys and clothing, and other items. It is also not uncommon for parents to have unrealistic expectations for the adolescents:  they often expect that their son or daughter will be able to implement the new system perfectly once it has been developed. It is important to validate parental frustration while helping them to set more realistic

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expectations. Their child has been doing things the old way for a long time, and it will take a while for the new system to become habitual. Review: Tools for Organizing and Planning







Use of calendar for managing appointments: Assess whether the adolescent has begun to use a calendar consistently. Discuss how frequently they use the calendar, making sure that they look at the calendar daily. Finally, discuss any problems that the client is having with using the calendar system. ■ Use of task list: Review any difficulties that the adolescent is having using the task list on a daily basis. Emphasize the importance of looking at and using the task list each and every day. ■ Use of the “A,” “B,” and “C” priority ratings:  If the client is having any trouble with prioritizing tasks, discuss this now. The adolescent should be prioritizing homework on a regular basis at this point. If not, assess the obstacles and make a plan to reduce barriers. ■ Use of problem-​ solving (selecting an action plan) and breaking down large tasks into small steps: Consider the client’s use of these strategies and practice one or both skills using examples from their current task list. ■

Introduction to Attention Span and Distractibility Adolescents with ADHD commonly report that they are unable to complete tasks because other, less important tasks or distractions get in the way. Having a short attention span is part of ADHD. We do not view having a short attention span as being associated with low intelligence or reduced ability. Rather, it represents a need for individuals with ADHD to use extra skills.

Skill: Gauging the Client’s Attention Span The purpose of this next exercise is to help clients estimate the length of time that they can work on a boring or unattractive task without stopping. In session, instruct the client to choose a boring

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or unattractive task to work on. If the adolescent has access to schoolwork, this can be used. If not, the adolescent can be given an article or book that is not likely to interest them. After starting the task, the adolescent should keep track of how long they can work before taking a break or becoming distracted. This exercise should be repeated several times to see if a consistent “attention span” emerges. The adolescent can practice this exercise during the week to gather additional information. Explain to the adolescent that there really is no such a thing as an exact amount of time that represents each individual’s attention span: it is different for everyone. The amount of time that one can work on a particular task will depend on many factors, including those related to the task (level of difficulty) and those related to the individual (how tired they are, level of interest in the task, whether they have eaten recently, etc.). What you are trying to gauge with this exercise is a reasonable amount of time that the adolescent can expect themselves to work on a boring task. Often, individuals with ADHD set unrealistic goals for themselves (e.g., “I am going to study for 8 hours straight”), and then they end up not wanting to start the task because the goal is so overwhelming. The next strategy is to help the adolescent use problem-​solving skills to break down important tasks into small steps that they can do within the allotted amount of time. You can discuss the fact that the client will be learning additional skills to help gradually increase the length of time that they can spend working on tasks. You should highlight the importance of scheduling blocks of time in which the client can work on tasks and also the importance of scheduling breaks between tasks. The break should have a specific time allotment so that the client does not end up having 30 minutes of work time followed by a 3-​hour break!

Skill: Implementing the Distractibility Delay The distractibility delay is an exercise that can be done in addition to the strategies just described. It is similar to an exercise used in

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anxiety-​ disorder treatments (e.g., Zinbarg, Craske, & Barlow, 2006)  and can be used as a strategy for delaying attending to distractions while working on boring or unattractive tasks. Clients with ADHD often report that it is difficult when a thought pops into their heads while they are working on a task. They say that it is tempting to simply stop working on their current task and shift to working on the new task. They report that this is because they worry about forgetting the new task and not completing it at all. The reality is that this has been the client’s experience in the past. Thus, the distractibility delay can be described as a tool for getting the distractions out of one’s head and “parking” them somewhere else, where they will not be forgotten, so that the client can focus on the task at hand. Over time, the client will gain confidence that these tasks will not be forgotten and will actually get done. Instruct the adolescent to have a piece of paper or a note app open on their phone or other device when starting to work on a boring or unattractive task. Then they should set a timer (they can use a phone or other device for this as well) for the agreed upon length of time (e.g., 30 minutes). When a distraction pops into their head, the client should write the distracting thought down on the piece of paper or in an electronic note but not take action at that time. Instead, the client should return to the task at hand. When the timer goes off, they can look at the list and decide if any of the distracting tasks need to be completed at that time. Instruct the client to repeat this process until the task is completed (or that portion of the task that the client has set out to do for the day). The client can then review the list of distractions and decide if (1)  they need to be completed at that time, (2)  they should be added to the client’s master or daily task list, or (3)  they are unimportant tasks that do not need to be completed. The piece of paper should then be discarded (or the electronic note should be deleted) at the end of the exercise so that the client does not end up with multiple lists. Also, explain to the client that they can use coping statements to help them return to the task at hand. These can include, “I will worry about this later,” “I don’t need to do this right now,” or “I will come back to this.” 80

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Clients can be instructed to use the distractibility delay in a similar fashion during classes or study groups. For example, if the client has difficulties with impulsively blurting out comments or questions, they can bring a notepad or tablet to meetings where they can write down a cue word or phrase and then try to refocus attention on what is happening in the class or study group. When there is a break in the conversation, the adolescent can bring up the question or comment.

Potential Pitfalls Adolescents may become frustrated if they aren’t able to immediately implement the distractibility delay and/​or increase the length of time that they can spend working on important or boring tasks. Encourage clients to look at this as a process that may take a while to improve. Remind them that it took many years to develop their old habits, and it is not realistic to expect that they will change overnight.

Practice The adolescent should:



Continue to use the calendar every day to keep track of their schedule and put homework and other tasks on the task list every day. ■ Use and look at the task list and calendar every day! ■ Use priority ratings. ■ Practice doing tasks according to the priority ratings they have set. ■ Carry over tasks that are not completed to the next day’s task list. ■ Practice using Worksheet 3:  Problem-​ Solving:  Selection of Action Plan or Worksheet 4:  Problem-​Solving:  Pick Three for at least one item on the task list. ■ Practice breaking down one large task from the task list into smaller steps using Worksheet 5: Problem-​Solving—​Small Steps. ■ Use the organizational systems developed in this program. ■ Measure attention span. ■ Use the distractibility delay when working on boring or unattractive tasks. ■

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CASE VIGNETTE Therapist: So, do you think you can try using the distractibility delay this week? Client: I don’t know. It seems like a lot of work. Therapist: Tell me about that. What about it seems like a lot of work? Client: I don’t know. It seems like I’m adding in more steps by having to always have something I  can use to write the distractions down on and then taking the time to go over the distractions after each block of time. Therapist: I hear you. You are getting basically “full” in terms of the steps you have to follow for this treatment. Client: Basically, yes. Therapist: Ok, so let me ask you this. What might be a problem if you were to just not make these changes? Client: What do you mean? Therapist: Well, what happens when you continue using the strategies you already have been using? Client: Well, that’s why I came to you in the first place. Therapist: So, do you think it makes more sense for you just to keep doing things the way you have been doing them in the past? Client: No, not really. I  usually start things, and then I  go off and start doing other things, and I  forget what I  was even working on in the first place. Therapist: So.  .  .  . What do you think about trying a different strategy? Client: You got me. Therapist: Ok, so let me ask you this: If it seems difficult to always have something nearby to write with, is there anything you could do to make that easier? Do you have a note app on your phone? Or if you usually do homework in the same spot, you could have a note pad nearby. Client: I think that using my phone could distract me, even though I do almost always have it with me. Maybe having a note pad on my desk would work better. Therapist: Do you want to give it a try? Client: Ok. It’s worth a shot. 82

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CHAPTER 7

Session 7: Optimize the Setting

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 6:  Strategies for Reducing Distractions, located in the Appendix ■ Alarm device ■



Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review progress ■ Review use of calendar, task list, and work from previous module ■ Teach the adolescent strategies for controlling the environment when trying to concentrate on homework or other tasks ■ Teach the client skills for keeping track of important items ■ Teach the adolescent to use reminders to help with skill consolidation ■ Instruct the client in use of alarm device to help with staying on task ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda. 83

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Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.

Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Signposts of Change For this session, the signposts of change are:



Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken down the task into smaller steps or completed a problem-​solving worksheet. ■ Client has started to implement a system for decreasing the amount of e-​mail and paper that comes in and needs to be dealt with. ■ Client has identified areas that require an organizational system and has started to implement the system as agreed upon. ■ Client has encountered situations where they needed to concentrate on a boring task and has attempted to use distractibility delay. ■

Review of Previous Sessions As always, this session includes a review of the adolescent’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties. It is important to focus on the fact that the client is attempting to use these skills, even if the outcome is not 100% perfect. You should continue to emphasize that the ineffective behavior patterns probably developed over many years, and it is not realistic to expect that they will completely change in just a few weeks. You can let the adolescent know that the fact that they are trying to notice times when they are behaving in an ineffective manner and then using skills to become more effective is most important at this stage.

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Review: Tools for Organization and Planning





Use of calendar for managing appointments: At this point, you should discuss any problems that the client is having using the calendar system. ■ Use of task list: Review any difficulties that the client is having with recording tasks and looking at the task list on a daily basis. ■ Use of the “A,” “B,” and “C” priority ratings:  If the client is having any trouble with prioritizing tasks, discuss this now. The adolescent should be prioritizing homework on a regular basis at this point. If not, assess the obstacles and make a plan to reduce barriers. ■ Use of problem-​ solving (selecting an action plan) and breaking down large tasks into small steps: Consider the client’s use of these strategies and practice one or both skills using examples from their current task list. ■

Review: Tools for Reducing Distractibility



Use of strategy for breaking down boring tasks into manageable chunks: At this point, discuss any problems that the adolescent is having breaking down large and/​or boring tasks into manageable chunks. ■ Use of the distractibility delay: Review any difficulties that the client is having with the distractibility delay technique. ■

Skill: Controlling the Homework Environment It is important for adolescents with ADHD to do homework in an environment that has few distractions. Even with the coping with distractibility skills discussed earlier, most people are somewhat distractible when they are trying to concentrate. Sometimes distractions interfere to the point where it is too difficult to get things done. When conducting this session, please refer back to the session in Chapter 5 on organizational systems. Instruct the client to think about things that typically are distracting while doing homework or trying to concentrate. These may include

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the ringing of the telephone, surfing the internet, replying to messages, going on social media, listening to music, watching shows or movies, noticing other things on the desk that require attention, speaking with other people in the room, or looking at something going on outside the window. Using Worksheet 6:  Strategies for Reducing Distractions, located in the Appendix, help the adolescent develop a plan for reducing problematic distractions. Strategies can include:

turning off the phone ■ moving phone to a different room ■ closing the web browser ■ turning off alerts on the phone ■ clearing off the desk or workspace ■ turning off music, radio, or television ■ asking siblings not to come into the room while the adolescent is working ■ sitting in such a way that the window or other distracting views are not visible. ■

This is an area where involving parents in the discussion is likely to be helpful. Adolescents often display a lack of awareness of situations that are distracting. We have often heard from adolescents that they try to do homework with their phone in hand, with alerts on, watching a show on their computer, etc., yet they don’t feel that these factors are responsible for the fact that it takes them hours to complete their homework. You may need to use motivational interviewing here to try to increase the adolescent’s willingness to try new strategies. Also, “testing it out” can help. They can try for a few days working while reducing these distractions and see if it helps in terms of getting work done. Interestingly, some individuals with ADHD report that they do not concentrate as well when they are in a totally silent environment. For these clients, try to help them articulate the circumstances that are the most helpful in aiding concentration. For example, many clients report that they concentrate better when there is a certain

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type of music playing in the background (often music that does not have lyrics that might be distracting). Instruct the client to find one place in their home where they can do schoolwork and other important tasks without distraction. This could be a desk or a table or any other “work space.” You can talk with the adolescent about setting the stage for success—​setting up the work environment so that it is conducive for them to be as productive as possible. Again, it can be helpful to include parents in this discussion so that they can have input into the solution that the adolescent is proposing. If the adolescent suggests that the best spot for them to work is at the kitchen table, but they want all other family members to stay out of the room, this may not be workable if they typically do homework at times when parents are preparing dinner and siblings are coming in and out and going to sports practices and other after school activities. Sometimes it can be helpful to talk with older adolescents about other settings where they can go to work, such as a coffee shop or a library where there may be fewer distractions. This is especially useful as adolescents prepare to transition from high school to college where they will have much more responsibility for managing their own schedules.

Skill: Keeping Track of Important Items One hallmark symptom of ADHD is frequently losing important items. This is problematic because it can cause individuals to be late and increase feelings of frustration. With adolescents, this can create frustration, not only for the individual, but also for their siblings and parents. If the adolescent with ADHD can’t find something and is late leaving the house, this may have a ripple effect, causing a parent to be late for work because she needs to drive the adolescent to school, a sibling to miss his bus, and so on. Ask the adolescent to think of any difficulties they have in keeping track of important items such as backpack, computer, school ID,

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house keys, or phone. The adolescent should pay special attention to those items that are needed each time they leave the house. Next, instruct the client to think of a specific place in the house where these items will be kept. This can include such strategies as leaving a basket near the door and placing the important items in the basket each time the client comes in the door. Encourage the client to think of one or more solutions that are likely to be effective. Parents should be involved in this discussion, especially if the proposed solution involves purchasing furniture or other home accessories, and if they will alter the appearance of the home or get in the way of other family members. Once a system has been proposed, instruct the client to involve other family members in the process. If everyone in the household is aware of where things belong, they can follow the system as well. Families may want to create a system that works for all family members, such as installing a storage unit in the entryway that has cubbies for each person’s coat and accessories. Every time a family member comes home, they place their outerwear in their own spot, and then everyone knows where to find their things when it is time to leave the house. Emphasize to the client the importance of putting an item in the appropriate place immediately if they notice something is out of place.

Skill: Using Reminders Another strategy for managing distractibility is to use reminders to cue clients to use their skills. An alarm device can be helpful to prompt the adolescent to check in with themselves on a regular basis about whether or not they are on-​task. Most phones have alarms that can be used for this purpose. Alternatively, the client can set up a task (or multiple repeating tasks during the day) on an electronic calendar with a label, “Am I on task?” Use an alarm to provide a reminder(s) on the device.

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When the alarm sounds, the adolescent should to ask themselves, “Am I doing what I am supposed to be doing, or did I get distracted?” If the client notices that they have become distracted, instruct them to immediately return to the task at hand.

Potential Pitfalls It is easy to get frustrated with these strategies if they don’t work right away. Remind clients that they are trying to develop new habits and that this takes time. Encourage them to think about the long-​term benefits of learning new habits. You can use motivational interviewing to build the adolescent’s motivation and willingness to try the strategies.

Practice The adolescent should:



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Continue to use the calendar every day to keep track of their schedule and put new tasks on the task list every day. ■ Use and look at the task list and calendar every day! ■ Use priority ratings. ■ Practice doing tasks according to the priority ratings. ■ Carry over tasks that are not completed to the next day’s task list. ■ Practice using Worksheet 3:  Problem-​ Solving:  Selection of Action Plan or Worksheet 4:  Problem-​Solving:  Pick Three for at least one item on the task list. ■ Practice breaking down one large task from the task list into smaller steps using Worksheet 5: Problem-​Solving—​Small Steps. ■ Use the organizational systems developed in this program. ■ Use the distractibility delay when working on boring or unattractive tasks. ■ Use skills to reduce distraction in the homework environment. ■ Start putting important items in specific places. ■ Use reminders to check in with themselves to see if they have become distracted when trying to focus on completing a task. ■

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CASE VIGNETTE Therapist: Would it be ok if we talk about things that might distract you when you are trying to do schoolwork or other things that require concentration? Client: Ok, thanks, sure. Therapist: Can you describe the situation when you are trying to do your homework? Client: I usually sit on my bed in my bedroom with my computer open in front of me. Sometimes I have a show on in the background, but I’m not really watching it. Therapist: Ok. What else is happening around you? Where is your phone? Client: I never go anywhere without my phone, so obviously that would be on my bed, right next to my computer. Therapist: Do you keep your sound on or off when you are studying? Client: I need to keep the sound on so I don’t miss any messages from my friends. Therapist: Do you usually keep the door to your room open or closed? Client: Open so that I can see what is going on in the house. Therapist: Where are your little brothers when you are studying? Client: They are usually running around and coming in and out of my room. Therapist: How do you feel this way of doing things is working for you? Client: Pretty well. Therapist: So do you feel like there are any changes you could make to reduce the likelihood that you will get distracted when you are studying? Client: I don’t know. I always feel like I’m working hard, but then it seems like it takes me a long time to finish each assignment, so maybe I’m not as focused as I think. Therapist: What changes do you think might be helpful? Client: Maybe I could try shutting my door so my brothers aren’t running in and out all the time. Therapist: That seems like a good one. Anything else?

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Client: I do sometimes get really distracted by my phone. Maybe I could turn off the sound and plug it into the charger on the other side of the room or in the kitchen, so I don’t look at it every time someone sends me a message. Therapist: That seems like it might be helpful. Any other ideas? Client: I tell myself that I’m really not watching the show that’s playing on my computer, but sometimes the show gets to an exciting place and I get sucked in and watch the show for a while and stop doing my homework. Therapist: I can see how that might happen. It sometimes feels like it is better to multitask, but it is actually more effective when you devote all of your attention to doing one thing at a time. Want to try those things this week and see how it goes? Client: Ok. I’ll try.

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MODULE 3

How to Be a Better Coach

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CHAPTER 8

Session 8: Thinking, Feeling, and Acting

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 7:  Three-​ Column Thought Record, located in the Appendix ■ Worksheet 8: Four-​Column Thought Record, located in the Appendix ■



Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review progress from previous sessions ■ Introduce the cognitive component of the cognitive behavioral model of ADHD ■ Discuss automatic thinking and the relationship of thoughts to behaviors and feelings ■ Explain how to identify negative thoughts ■ Introduce the list of thinking errors ■ Discuss labeling thinking errors using Worksheet 8:  Four-​ Column Thinking Record ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for 95

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what lies ahead in the upcoming session. Use the preceding session outline to set the agenda.

Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.

Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Signposts of Change For this session, the signposts of change are:







Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken down the task into smaller steps or completed a problem-​solving worksheet. ■ Client has started to implement a system for decreasing the amount of e-​mail and paper that comes in and needs to be dealt with. ■ Client has identified areas that require an organizational system and has at least started to implement the system as agreed upon with you. ■ Client has encountered situations where they needed to concentrate on a boring task and has attempted to use the distractibility delay. ■ Client has identified a home for important items and has started placing the important items in the designated spot on a regular basis. They have shared information about their system with family members. ■ Client has attempted to use strategies for reducing distractibility that were identified in session. ■ Client has started using an alarm to check in with themselves to see if they have become distracted when working on important or difficult tasks. ■

Review of Previous Sessions As always, this session includes a review of the adolescent’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties. 97

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It is important to focus on the fact that the adolescent is attempting to use these skills, even if the outcome is not 100% perfect. You should continue to emphasize that the ineffective behavior patterns probably developed over many years, and it is not realistic to expect that they will completely change in just a few weeks. You can let the client know that the fact that they are trying to notice times when they are behaving in an ineffective manner and then using skills to become more effective is most important at this stage. It is essential to also send this message to parents. Parents may expect that adolescents should be able to change their behaviors immediately since they are participating in a treatment program. If parents communicate frustration to their child, this can upset the adolescent and impede progress.

Review: Tools for Organization and Planning



Use of calendar for managing appointments, meetings, and other commitments: At this point, you should discuss any problems that the adolescent is having using the calendar system. ■ Use of task list: Review any difficulties that the client is having with recording tasks and looking at the task list on a daily basis. ■ Use of the “A,” “B,” and “C” priority ratings: If the adolescent is having any trouble with prioritizing tasks, discuss the difficulties at this point. ■ Use of problem-​ solving (selecting an action plan) and breaking down large tasks into small steps: Consider the client’s use of these strategies and practice one or both skills using examples from their current task list. ■

Review: Tools for Reducing Distractibility



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Use of strategy for breaking down boring tasks into manageable chunks: At this point, you should discuss any problems that the adolescent is having breaking down large and/​or boring tasks into manageable chunks. ■ Use of the distractibility delay: Review any difficulties that the client is having with the distractibility delay technique. ❑ Use of strategy to remove distractions from the environment. ■

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Use of strategy to have a specific place for each important object. ■ Use of reminders and alarms: “Am I doing what I am supposed to be doing?” ■

Introduce the Cognitive Behavioral Model of ADHD By now, you have worked with your client to develop systems for organizing, planning, and problem-​solving and to practice skills for managing distractibility. The next section, adaptive thinking, will teach adolescents to increase their awareness of negative and/​or unhelpful thoughts that can cause stress and mood problems and can interfere with the successful completion of tasks. This method of learning to think adaptively has been used in similar cognitive behavioral treatments and has been effective in treating many other psychological disorders such as depression and anxiety disorders.1 The major goal of learning to think about tasks and situations adaptively is to reduce the frequency of times when negative and/​or unhelpful thoughts or moods interfere with tasks or follow-​through, contribute to procrastination, or add to distress or distractibility. Your aim is to communicate the message that negative and/​or unhelpful thoughts can interfere with the adolescent using the new strategies that they recently learned. However, clients can learn strategies for removing these barriers and thereby more effectively manage ADHD symptoms. Adaptive thinking will enable clients to:

Increase their awareness of negative, interfering thoughts, ■ Increase their awareness of unhelpful thoughts, ■ Develop strategies for keeping thoughts in check, and ■ Minimize symptoms. ■

Adaptive thinking is important because of the interrelationship between thoughts, feelings, and behaviors. This model emphasizes the important connection between thoughts, feelings, and behaviors in a given

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This method of implementing and teaching cognitive-​restructuring skills is based on McDermott (2000), as well as other CBT therapy manuals including the Hope, Heimberg and Turk (2006) manual for the treatment of social anxiety, and the Otto and Pollock (2009) manual for treatment of panic disorder in the context of medication discontinuation.

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Thoughts

Feelings

Behaviors

Figure 8.1 Basic Cognitive Behavioral Model. situation, as illustrated in Figure 8.1. The cognitive part of cognitive behavioral therapy (CBT) refers to the fact that thoughts influence how people act and feel. The Cognitive Component of Treatment: Automatic Thinking The goal of this section is to highlight the role of negative and/​or unhelpful thoughts in ADHD symptoms. First discuss the automatic nature of thoughts. Some thoughts happen so quickly that they are not in our present awareness. Furthermore, automatic thoughts can be detrimental when they are characterized by negative content. You might present this concept in the following manner: In the course of a given day, numerous thoughts go through our minds. What is surprising is that we often are not aware of these thoughts. However, they play an important role in determining how we are feeling in a situation and how we may act. When we are feeling overwhelmed or stressed or are anticipating completing a task, the thoughts that go through our minds play a critical role in determining the outcome of the situation. These thoughts are “automatic”: they happen on their own. For example, think about when you first learned to ride a bike. In order to coordinate many tasks at once, you had to be conscious of where your hands were placed on the handle bars, remember to look both ways before turns, ride in a straight line, and watch out for other traffic. You were doing many tasks at the same time that required your total attention. Now, think about riding a bike today. You probably know how to ride without actively thinking about what you are doing. You likely don’t 100

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even remember thinking about all of these steps because they have become automatic. This can be a positive thing in that it frees up your attention to focus on other things, like what you will do when you get to work, or what you need to pick up from the grocery store later on. However, if the thoughts are negative in tone, this can be problematic.

Less Helpful Automatic Thinking In many situations, like the one we just discussed, automatic thoughts enable us to complete a task more easily. Unfortunately, in other situations, automatic thoughts interfere with achieving goals. For example, imagine you have to do a task that you will probably not enjoy, such as preparing for a big exam or writing a term paper. Imagine the following types of thoughts going through your mind: “I am careless and am going to do this wrong.” “This is going to take forever.” “I’m probably going to fail this test.” “I will never get all of my homework finished.” If these thoughts are going through your head, then you can easily see that this task will feel overwhelming and stressful. This will increase the chance that you will procrastinate by doing any other possible task.

Thinking That Is Too Positive So far, we have talked about negative automatic thoughts. However, researchers are now identifying another problematic way of thinking in individuals with ADHD that involves overly optimistic thinking. These authors claim that adults with ADHD often set overly optimistic goals and verbalize overly positive thoughts. We have frequently observed this pattern in adolescents with ADHD as well. This pattern can cause difficulties in that individuals feel good in the moment (e.g., “I don’t really need to do this today because I have plenty of time to do it next weekend”). However, it causes problems when the thinking and goal-​setting are unrealistic, and the person ends up failing to meet their goals. Thus, we will be working on identifying these overly positive thoughts in addition to helping you identify negative thoughts. 101

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Relationship of Thoughts to Feelings and Behaviors To help the adolescent client understand why it is important to identify and change maladaptive thinking, discuss the relationship between automatic thinking and behavioral outcome, which is often some form of avoidance. Negative automatic thoughts about a situation can cause people to avoid the situation because they (1) feel worse and (2) expect the outcome of the situation to be negative. Avoidance can lead to more anxiety, restlessness, and perhaps irritability or depression because the task doesn’t get done, and then the person feels worse about it. Along the same lines, overly positive thinking can lead to avoidance or procrastination as well. Even though the accompanying affect is very different, the outcome is the same: the individual with ADHD avoids the task and ultimately it does not get done on time, does not get done well, or does not get done at all. Anxiety and depression may lead to more negative thinking, and around and around the cycle goes, making the problem worse and worse. For people with ADHD, this cycle exacerbates other symptoms such as inattention, procrastination, frustration, and depression. The first step in breaking this cycle is to identify and slow down negative or ineffective, automatic thinking. Becoming more aware of situations when this occurs is the first step in learning to think in more adaptive ways.

Skill: Identifying Negative/​Unhelpful Automatic Thoughts The “thought record” is a tool that was developed to help clients learn how to identify, slow down, and restructure negative or unhelpful, automatic thoughts. Clients may use the thought records provided in the Appendix (Worksheets 7 and 8)  or they can write the information in a notebook or on their phone, tablet, or computer. There are various apps that can be purchased for phones and tablets to assist with the completion of thought records. Complete at least one thought record in session with the client to make sure they understand how it is done. You can refer to the “Preliminary Instructions for Adaptive Thinking” section later

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in this chapter and in Chapter  8 of the Client Workbook when completing the thought record. Remind the adolescent that they can refer back to these instructions if needed when completing the thought records on their own. Ask the adolescent to identify one distressing situation they experienced in the past week or a time when they felt overwhelmed, stressed, sad, or upset. You can also ask the client to try to look for thoughts they may have had that were overly optimistic and unhelpful. These thoughts can be harder to identify in the moment because there is not a negative affect associated with them. After the fact, clients can identify these thoughts more easily. It is important to have the adolescent (not the therapist) write out the thought records so that the client becomes familiar with their format. Worksheet 7:  Three-​Column Thought Record should be completed by the client as follows: Ask the client to write a brief description of the situation in Column 1:

When did it take place? ■ Where was the adolescent? ■ With whom? ■ What was going on? ■

Ideally, the description of the situation should be a sentence or two at most. Then, instruct the client to write down all of their automatic thoughts in Column 2:

What was going through their mind at the time? ■ What was the adolescent saying to themselves about the situation? To other people? ■ What was their role in the situation? ■ What were they afraid might happen? ■ What is the worst thing that could happen? ■ If there is another person involved, what does this mean about how they feel/​think about the adolescent? ■

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Therapist Note: When coming up with automatic thoughts, it is important to help clients separate thoughts from feelings. Gently instruct clients that thoughts are ideas going through their minds during the situation; feelings go in the next column. Next, ask the client to list in Column 3 all of the feelings they experienced (there may be several different feelings) and then rate the intensity of each feeling on a scale of 0–​100 (where 0 = the least intense, 100 = the most intense). Examples of feelings include angry, upset, happy, sad, depressed, anxious, and surprised. Figure 8.2 is an example of a completed three-​column thought record. Provide a blank Three-​Column Thought Record (such as Worksheet 7 in the Appendix) for in-​session practice.

Introduce Thinking Errors or Thinking Traps Now that clients see how certain situations can trigger negative, automatic thoughts and subsequent negative feelings, our goal is to help them understand why their thoughts are unhelpful and to recognize errors in thinking. In our experience, and in the work of other cognitive behavioral therapists, common types of negative automatic thoughts often emerge. These types of thoughts may interfere with the adolescent’s ability to complete tasks and also may contribute to feelings of depression, anxiety, or frustration.

Figure 8.2 Sample completed Three-​Column Thought Record. 104

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Listed here are common thinking errors that are sometimes referred to as “thinking traps.”2 Review each one with the client to make sure they understand them all. Help clients look for patterns and determine which types of errors may be especially problematic for them.

Common Thinking Traps









All or nothing thinking: You see things in black-​and-​white categories. For example, all aspects of a project need to be completed immediately, or, if your performance falls short of perfect, you see it as a total failure. ■ Overgeneralization: You see a single negative event as a never-​ ending pattern (it will continue to happen every time you do this activity). ■ Mental filter: You pick out a single negative detail and dwell on it exclusively, overlooking other positive aspects of the situation. For example, if you got 5 questions wrong on an exam, even though you got 20 right, you would focus on the questions you got wrong. ■ Disqualifying the positive: You reject positive experiences by insisting that they “don’t count” for some reason or other. In this way, you can maintain a negative belief that is contradicted by your everyday experiences. ■ Jumping to conclusions:  You make a negative interpretation even though there are no definite facts that convincingly support your conclusion. ■ Mind reading: You conclude that someone is reacting negatively to you or doesn’t like you, and you don’t bother to check this out. ■ Fortune telling: You anticipate that things will turn out badly, and you feel that your prediction is a predetermined fact. ■ Magnification/​Minimization: You exaggerate the importance of things (such as your mistake or someone else’s achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or other people’s imperfections). ■

2

This list is taken from Hope, Heimberg, Juster, and Turk (2006), with some modifications. The list from Hope et al. (2006) was, in turn, based on Persons (1989). Overly optimistic thinking is derived from Knouse and Mitchell (2015).

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Catastrophizing: You attribute extreme and horrible consequences to the outcomes of events. For example, one mistake at work will mean being fired from your job. ■ Emotional reasoning: You assume that your negative emotions necessarily reflect the way things really are: “I feel it, so it must be true.” ■ “Should” statements: You try to motivate yourself with “shoulds” and “shouldn’ts,” as if you need to be punished before you could be expected to do anything. When directed toward others, you feel anger, frustration, and resentment. ■ Labeling and mislabeling: This is an extreme form of overgeneralization. Instead of describing an error, you attach a negative label to yourself or others. An example of this would be calling yourself a “loser” or a “jerk.” ■ Personalization: You see negative events as indicative of some negative characteristic of yourself or others, or you take responsibility for events that were not your doing. ■ Maladaptive thinking: You focus on a thought that may be true but over which you have no control. Excessively thinking about it can be self-​critical or can distract you from an important task or from attempting new behaviors. ■ Overly optimistic thinking: You think about a situation in an overly optimistic way that feels good in the moment but leads to procrastination and/​or avoidance and is not effective in the long run. For example, you decide not to start working on your project today because you tell yourself that you will definitely have time to do it on the weekend. ■

Skill: Labeling Thinking Traps After the client has learned about common types of thinking errors, go back to the Three-​Column Thought Record they filled out with you earlier and ask them to rewrite their automatic thoughts on Worksheet 8:  Four-​Colum Thought Record (located in the Appendix). For each of the automatic thoughts listed, review the list of thinking errors and help the adolescent identify the common patterns in their thinking. Then, list the appropriate thinking error in Column 4 on Worksheet 8. Sometimes more than one thinking

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error is made, and there may be some overlap among different types of errors. Therapist Note: The goal of this exercise is for clients to see that they are falling into thinking traps. Though it might be ideal for them to pick the exact type of trap they are falling into, there is no real need to get too wrapped up in figuring out if it is one trap versus another. It is important to remind clients that not all negative thoughts represent thinking traps. Sometimes it is realistic that a situation produces a negative thought, which, in turn, contributes to a negative feeling. We offer the following example to illustrate this: Imagine you had been studying for an exam for many days and you were driving to school to take the exam. Then, suddenly you encountered a traffic jam due to a car accident that occurred earlier. Now, if your thought was “Oh no, . . . I hope I won’t be late! I studied so hard for this exam,” and you were feeling anxious and perhaps frustrated, that would make sense! The challenge for you would be to problem-​solve—​to try and stay calm, perhaps call the instructor to let her know that you are going to be late, and to focus on driving safely. However, if, in addition to those thoughts, you also said to yourself, “Bad things always happen to me, I  can never do anything right, I am going to miss the exam and fail the class,” we can imagine that your anxiety and despair would intensify, and you may be more likely to drive dangerously, get in an accident, and not be able to take the exam. Furthermore, if you did get to the exam in time, you most likely would be distracted by these intense emotions and would be less able to concentrate compared to when you were studying. Looking closely, you can see that these thoughts, respectively, could be classified as overgeneralization, personalization, and jumping to conclusions. Refer to Figure 8.3, which is an example of a completed Four-​ Column Thought Record, and then provide clients with copies of the Four-​Column Thought Record (Worksheet 8) to complete on their own.

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Figure 8.3 Sample completed Four-​Column Thought Record. Potential Pitfalls Often individuals feel that it is impossible to change how they think. It is important to acknowledge that change does not occur overnight, but clinical experience and research suggest that it is possible. Sometimes monitoring thoughts alone can begin the process of change. For especially skeptical clients, it can be helpful to suggest they do an experiment:  For the next month, they will commit to using thought records to monitor their thoughts, label unhelpful thoughts, and attempt to identify more rational responses. If, at the end of this 1-​month experiment they detect absolutely no change, they may consider returning to their dialogue of negative thoughts. However, it is likely that with consistent monitoring and practice, they will begin to see improvement. For some people, writing out negative thoughts makes the thoughts “seem more real” or more difficult to cope with. Because of this, they are reluctant to utilize thought records. However, the thoughts are in their minds, interfering, regardless of whether or not they write them down. Completing the thought record will actually help them feel better about the situation, despite the initial difficulty of seeing their thoughts on paper.

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Clients may also find that it is hard to label their feeling(s) and may think that they have to come up with the perfect words to describe their feelings. Ask them to use the first word that comes to mind, even if it is not perfect. Over time, it will become easier to label their feelings. Therapist Note: As has been emphasized in previous modules, practice is vital so that the skills become more familiar and individuals are able to easily use the tools and begin to see the positive results that can emerge when they consistently use these CBT strategies. Remind adolescents that, at first, when they are learning a new skill, it may feel awkward, may be confusing, and may require effort to implement. That’s ok! The more they practice, the easier it will become. In this session, try to anticipate challenging situations the adolescent might encounter in the upcoming week. In addition, be sure to anticipate any problems that may get in the way of practicing this skill. For example, having a busy sports schedule, going out of town, or being uncertain about how to complete an assignment may make it more difficult for adolescents to practice skills. We have found that if clients can work with their therapist to anticipate and problem-​solve in advance, these obstacles can become manageable, and clients will be more likely to achieve success with the new skills. Also remind adolescents that they do not have to complete these home assignments perfectly! The idea is for them to begin monitoring the thoughts that arise in difficult situations and begin to practice identifying the common types of thinking traps.

Preliminary Instructions for Adaptive Thinking The purpose of using thought records is to identify and modify negative, automatic thoughts in situations that lead to feeling overwhelmed. The first step in learning to think in more useful ways is to become more aware of these thoughts and their relationship to your feelings. If you are anticipating a stressful situation, or a task that is making you feel overwhelmed, write out your thoughts about this situation.

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If a situation has already passed and you find that you are thinking about it negatively or if, after the fact, you realize that you were having unhelpful thoughts, list your thoughts for this situation.





The first column is for you to write out a description of the situation. ■ The second column is for you to list your thoughts during a stressful, overwhelming, or uncontrollable situation. ■ The third column is for you to write down what emotions or feelings you are having when thinking these thoughts (e.g., depressed, sad, angry). ■ The fourth column is for you to see if your thoughts match the list of “thinking traps” and, if so, to write the “thinking traps” here. These may include: ■ All or nothing thinking ■ Overgeneralization ■ Mental filter ■ Disqualifying the positive ■ Jumping to conclusions ■ Mind reading ■ Fortune telling ■ Magnification/​Minimization ■ Catastrophizing ■ Emotional reasoning ■ “Should” statements ■ Labeling and mislabeling ■ Personalization ■ Maladaptive thinking ■ Overly optimistic thinking ■

Practice The adolescent should:

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Continue to use the calendar every day to keep track of their schedule and put new tasks on the task list every day. ■ Use and look at the task list and calendar every day! ■ Use priority ratings. ■ Practice doing tasks according to the priority ratings. ■

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Carry over tasks that are not completed to the next day’s task list. ■ Practice using Worksheet 3:  Problem-​ Solving:  Selection of Action Plan or Worksheet 4:  Problem-​Solving:  Pick Three for at least one item on the task list. ■ Practice breaking down one large task from the task list into smaller steps. ■ Use the organizational systems developed in this program. ■ Use the distractibility delay when working on boring or unattractive tasks. ■ Use skills to reduce distraction in the homework environment. ■ Start putting important items in specific places. ■ Use reminders to check in with themselves to see if they have become distracted when trying to focus on completing a task. ■ Read the “Preliminary Instructions for Adaptive Thinking” on how to complete a thought record. ■ Write out examples of thoughts on Worksheet 8 for at least two situations during the week. ■

CASE VIGNETTE Therapist: Would it be ok with you if we practice writing down some thoughts together and then you will be able to work on them at home this week? Client: To be honest, I  really don’t see how writing down my thoughts is going to change anything. I’m not always going to have a worksheet with me that I can complete when I run into problems. Therapist: Those are really good points. So you think it is totally useless to write down your thoughts and see if they are overly negative? Client: Well, I don’t know. I do think sometimes I get carried away. Therapist: Ok. Well, let me say this: Many people aren’t sure how writing down their thoughts can be helpful until they start practicing. Does that make sense? Client: I guess so. Therapist: Can I explain it further? Client: Ok.

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Therapist: Here is what happens. What people find is that seeing their thoughts on paper helps them identify when the thoughts are unrealistic and highlights the connection between unhelpful, negative thoughts and feelings like anxiety, which can lead to procrastination. Also, I don’t expect that you will always need to write down your thoughts. Over time, with lots of practice, you will start to catch yourself having negative thoughts and will be able to change them in your mind. The whole process will become automatic. But for now, while you are learning, it is helpful to slow down the process and write out a thought record. I wonder if we can also think about whether there is an easier way for you to keep track of your thoughts. It makes sense that you won’t always be able to take out a piece of paper and write down your thoughts. Is there something that might be easier for you? Client: It would probably work better to use my phone. I could type stuff into a note. Therapist: There are also apps that you can get if you prefer. Client: I think I can type my thoughts into a note for now, but maybe I’ll get the app later. Therapist: Sounds good. If you can bring in a couple of examples next time, we can talk about what you can do with the negative thoughts.

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­C HAPTER 9

Session 9: Self-​Coaching

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 9: Five-​Column Thought Record ■

Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review progress from previous sessions ■ Review thought records completed since last session ■ Discuss coaching styles and coaching story ■ Discuss formulation of more helpful alternative thoughts ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda. Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of 113

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symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.

Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed.

ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Signposts of Change For this session, the signposts of change are:

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Client is attempting to use calendar and task list systems on a daily basis.

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Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating a daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken the task down into smaller steps or completed a problem-​solving worksheet. ■ Client has started to implement a system for decreasing the amount of e-​mail and paper that comes in and needs to be dealt with. ■ Client has identified areas that require an organizational system and has started to implement the system as agreed upon with you. ■ Client has encountered situations where they needed to concentrate on a boring task and has attempted to use the distractibility delay. ■ Client has identified a home for important items and has started placing the important items in the designated spot on a regular basis. They have shared information about their system with family members. ■ Client has attempted to use strategies for reducing distractibility that were identified in session. ■ Client has started using an alarm to check in with themselves to see if they have become distracted when working on important or difficult tasks. ■ Client has completed a thought record with at least one example of thoughts that occurred during the week and brought it to the session. ■

Review of Previous Sessions As always, this session includes a review of the client’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties. Remember, repetition of new skills is critical for individuals with ADHD and will maximize gains made in treatment.

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At this stage, it is important to see that the client is attempting to complete thought records. It may seem “silly” to some clients to go through this exercise. However, you can emphasize the importance of getting thoughts “out of one’s head” so that they can be evaluated more objectively. If the client did not complete a thought record, this can be done in session using examples of thoughts that the client recalls from the previous week.

Review: Tools for Organization and Planning





Use of calendar for managing appointments, meetings, and other commitments: At this point, you should discuss any problems that the adolescent is having using the calendar system. ■ Use of task list: Review any difficulties that the client is having with recording tasks and looking at the task list on a daily basis. ■ Use of the “A,” “B,” and “C” priority ratings:  If the adolescent is having any trouble with prioritizing tasks, discuss the difficulties at this point. ■ Use of problem-​ solving (selecting an action plan) and breaking down large tasks into small steps: Consider the client’s use of these strategies and practice one or both skills using examples from their current task list. ■

Review: Tools for Reducing Distractibility



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Use of strategy for breaking down boring tasks into manageable chunks: At this point, you should discuss any problems that the adolescent is having breaking down large and/​or boring tasks into manageable chunks. ■ Use of the distractibility delay: Review any difficulties that the client is having with the distractibility delay technique. ■ Use of strategy to remove distractions from the environment. ■ Use of strategy to have a specific place for each important object. ■ Use of reminders and alarms: “Am I doing what I am supposed to be doing?” ■

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Review: Tools for Developing Adaptive Thinking

Use of thought records (either on paper or electronically) to identify and label automatic thoughts. Review any difficulties that the adolescent reports with using this strategy.

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Review the thought records that the client completed at home. If the adolescent was not able to complete any thought records, try to identify the obstacles that may have interfered and utilize the problem-​ solving skills to determine the best way for them to work on automatic thinking. Did they have difficulty making time for home practice? Were the directions confusing? Was it difficult for the client to see their thoughts in writing? It is possible to work with the client on rethinking the situation in their head versus on paper. We have found that writing out automatic thoughts helps people step back from their thoughts and better identify the difference between thoughts and emotions. However, in reality, it can sometimes be difficult to get clients with ADHD to take the time to monitor their thoughts. If the adolescent didn’t do any home practice, work on a thought record together before moving on. Continue to emphasize the importance of reviewing skills in between sessions. If the client did complete thought records, review each one. Provide feedback on successful completion and assist the adolescent in identifying any patterns that are occurring with their negative thoughts. Often clients have a tendency to engage in particular thinking errors. Once this is recognized, the adolescent can begin to modify their thoughts.

Skill: Formulating a Rational Response In this session, the adolescent will learn strategies to develop more helpful thoughts. Our goal is to help transform unhelpful, interfering thoughts into more supportive, coaching thoughts. To understand how powerful thoughts can be, we tell the following coaching story.

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Coaching Story This is a story about Little League Baseball.1 I talk about Little League Baseball because of the amazing parents and coaches involved. And by “amazing” I don’t mean good. I mean extreme. You will see how it relates to ADHD and how you talk to yourself. But this story doesn’t start with the coaches or the parents: it starts with Johnny, who is a little league player in the outfield. His job is to catch fly balls and return them to the infield players. On this particular day, Johnny is in the outfield. And “crack!”—​one of the players on the other team hits a fly ball. The ball is coming to Johnny. Johnny raises his glove. The ball is coming to him, it is coming to him. . . . Johnny jumps up as high as he can, but he is in the wrong place at the wrong time using the wrong strategy, so it goes over his head. Johnny misses the ball, and the other team scores a run. Now there are a number of ways a coach can respond to this situation. Let’s take the head coach who is named Coach A first. Coach A is the type of coach who will come out on the field and shout “I can’t believe you missed that ball! Anyone could have caught it! My dog could have caught it! You screw up like that again and you’ll be sitting on the bench! That was lousy!” Coach A then storms off the field. At this point, if Johnny is anything like I am, he is standing there, tense, tight, trying not to cry, and praying that another ball is not hit to him. If a ball does come to him, Johnny will probably miss it. After all, he is tense, tight, and may see four balls coming to him because of the tears in his eyes. Also, if we are Johnny’s parents, we may see more profound changes after the game: Johnny, who typically places his baseball glove on the mantle, now throws it under his bed. And before the next game, he may complain that his stomach hurts, and say that perhaps he should not go to the game. This is the scenario with Coach A. Now let’s go back to the original event and play it differently. Johnny has just missed the fly ball, and now Coach B who is the assistant coach comes out on the field. Coach B says “Well you missed that one. Here is what I want you to remember: fly balls always look like they are farther away than they really are. Also, it is much easier to

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run forward than to back-​up. Because of this, I want you to prepare for the ball by taking a few extra steps backward. Run forward if you need to, but try to catch it at chest level so you can adjust your hand if you misjudge the ball. Let’s see how you do next time.” Coach B leaves the field. How does Johnny feel? Well, he is not happy. After all, he missed the ball—​but there are a number of important differences from the way he would feel with Coach A. He is not as tense or tight, and if a fly ball does come to him, he knows what to do differently to catch it. And because he does not have tears in his eyes, he may actually see the ball accurately. He may catch the next one. So, if we were the type of parent who eventually wants Johnny to make the major leagues, we would pick Coach B because he teaches Johnny how to be a more effective player. Johnny knows what to do differently, may catch more balls, and may excel at the game. But if we don’t care whether Johnny makes the major leagues—​because baseball is a game, and one is supposed to be able to enjoy a game—​ then we would still pick Coach B. We pick Coach B because we care whether Johnny enjoys the game. With Coach B, Johnny knows what to do differently; he is not tight, tense, and ready to cry; he may catch a few balls; and he may enjoy the game. And he may continue to place his glove on the mantel. Now, while we may all select Coach B for Johnny, we rarely choose the idea of Coach B for the way we talk to ourselves. Think about your last mistake. Did you say, “I can’t believe I did that! I am so stupid! What a jerk!” These are Coach A thoughts, and they have approximately the same effect on us as they do on Johnny. They make us feel tense and tight, and they sometimes make us feel like crying. And this style of coaching rarely makes us do better in the future. Even if you are only concerned about productivity (making the major league), you would still pick Coach B. And if you were concerned with enjoying life while guiding yourself effectively for both joy and productivity, you would still pick Coach B. Keep in mind that we are not talking about how we coach ourselves in a baseball game. We are talking about how we coach ourselves in life and our enjoyment of life. People with excessive distress, and

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many with ADHD are often anxious and distressed, tend to talk to themselves this way. During the next week, I would like you to listen to how you are coaching yourself. And if you hear Coach A, remember this story and see if you can replace Coach A with Coach B. This story is meant to help the adolescent recognize negative and/​or unhelpful thoughts as they pop up (Coach A thoughts) and to learn to develop more supportive, rational thinking (Coach B thoughts). After telling the coaching story, go back to one of the thought records previously completed by the client at home or discuss one completed in session together. Review the automatic thoughts and thinking errors that were identified. The next step is to evaluate the helpfulness of each thought. The following questions are suggested prompts to help clients objectively evaluate these thoughts.

■ ■ ■ ■ ■ ■ ■ ■ ■

What is the evidence that this thought is true? Is there an alternate explanation? What is the worst thing that can happen? Has this situation unreasonably grown in importance? What would a good coach say about this situation? Have I done what I can to control it? If I were to do anything else, would this help or hinder the situation? Am I worrying excessively about this? What would a good friend say to me about this situation? What would I say to a good friend about this situation if they were going through it? ■ Why is this statement a thinking error? ■ Is it helpful to focus on this thought at this moment? ■

Sometimes a client can maintain a strong belief that the negative thought is true. One strategy is to acknowledge the part of it that seems true, but to encourage the client to check in with themselves to make sure that the intensity is appropriate and to see if they are evaluating the worst-​case scenario if it is true. Alternatively, it can be helpful to suggest that the adolescent return to this thought another time because it is hard to work on it right now. You can also point out that sometimes thoughts can be true (e.g., “I didn’t study as much as I would have liked for that test”), and it is still not helpful 120

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to focus on them in a particular situation (e.g., as one is walking into the classroom to take the test in question). In that case, the strategy is not necessarily to argue with oneself about whether or not the thought is true, but simply to point out that it is unhelpful to focus on the thought at this time.

Five-​Column Thought Record We now introduce Worksheet 9:  Five-​Column Thought Record (located in the Appendix), which has an additional (fifth) column for formulating a more helpful alternative thought. The alternative thought is a statement that the client can say to themselves to try to feel better about the situation. Keep in mind that we are not asking the client to overlook all negative aspects of their thoughts. The idea is to come up with a more balanced, objective, and helpful way of thinking about the situation. For example, consider Johnny’s thoughts from the coaching story: “I am so stupid . . . I missed that ball. I’ll never become a good baseball player. I’ll always be a failure.” The goal would be for him to acknowledge that he missed the ball on this one occasion but has caught others in the past (no magnification/​minimization), to recognize that there are additional skills he can learn to help him become a better player (no fortune telling), and to see himself as having as good a chance as the next boy to become a good ball player (no catastrophizing). Please see Figure 9.1 for some examples of negative/​ unhelpful thoughts and the corresponding more balanced, helpful thoughts. 1

This story is adapted from Otto (2000) and Otto et al. (2009).

Potential Pitfalls We have discussed several different types of thinking traps that can contribute to negative feelings. While it is important for the client to be familiar with the types of thinking traps they may be falling into, remind them not to get stuck trying to find the exact type of thinking trap that corresponds with the thought. Thoughts may fit into more than one 121

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Figure 9.1 Sample completed Five-​Column Thought Record. category, and often these categories of thinking traps overlap. The goal is for the client to recognize that the automatic thought might represent a thinking trap, to understand why this is true, and, most importantly, to come up with an effective alternative thought. For many adolescents, identifying effective alternative thoughts may be tricky at first. Refer to the previous suggested questions (i.e., What would you say to a good friend about this situation if they were going through it?). Also, tell your clients to keep in mind that thoughts and feelings about the situation may not completely change immediately after identifying an alternative thought. However, if they practice repeating the alternative thoughts to themselves, over time they will begin to replace the negative and/​or unhelpful automatic thoughts with more balanced and effective ones.

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Therapist Note: Remind clients that, with practice, they will feel more comfortable using their new skills and will begin to notice improvements. In session, identify situations to work on at home using the thought records. Also ask the adolescent to consider any difficulties they may have in completing this assignment and problem-​solve to minimize the chance that obstacles will stop them from completing home practice.

Instructions for Completing a Five-​Column Thought Record The purpose of adaptive thinking is to help promote optimal thinking when we are feeling stressed. Throughout the week, whenever your client is feeling stressed, sad, or overwhelmed, they should continue to list their thoughts in each situation. If they anticipate a stressful situation or a task that is making them feel overwhelmed, they should write out their thoughts regarding this situation. If a situation has already passed, and they find themselves thinking about it negatively, they should list their thoughts for this situation.





The first column is for writing a description of the situation. ■ The second column is for listing thoughts during a stressful, overwhelming, or uncontrollable situation. ■ The third column is for writing down what emotions the client is having and what their mood is like when thinking these thoughts (e.g., depressed, sad, angry). ■ The fourth column is for examining if the client’s thoughts match the list of “thinking traps” and, if so, to write down the “thinking traps”. These may include: ■ All or nothing thinking ■ Overgeneralization ■ Mental filter ■ Disqualifying the positive ■ Jumping to conclusions ■ Mind reading ■ Fortune telling ■ Magnification/​Minimization ■ Catastrophizing ■ Emotional reasoning ■ “Should” statements ■

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Labeling and mislabeling ■ Personalization ■ Maladaptive thinking ■ Overly optimistic thinking ■ The last column is for the client to try to come up with an alternative thought to replace each negative automatic thought—​or the most important negative automatic thought. The alternative thought is a statement that the client can say to themselves to try to feel better about the situation. Questions to help come up with this alternative thought can include: ■ What is the evidence that this thought is true? ■ Is there an alternate explanation? ■ What is the worst thing that can happen? ■ Has this situation unreasonably grown in importance? ■ What would a good coach say about this situation? ■ Have I done what I can do to control it? ■ If I were to do anything else, would this help or hinder the situation? ■ Am I worrying excessively about this? ■ What would a good friend say to me about this situation? ■ What would I say to a good friend about this situation if they were going through it? ■ Why is this statement a thinking error? ■ Is it helpful to focus on this thought at this moment? ■

Practice The adolescent should:

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Continue to use the calendar every day to keep track of their schedule and put new tasks on the task list every day. ■ Use and look at the task list and calendar every day! ■ Use priority ratings. ■ Practice doing tasks according to the priority ratings. ■ Carry over tasks that are not completed to the next day’s task list. ■ Practice using Worksheet 3:  Problem-​ Solving:  Selection of Action Plan or Worksheet 4:  Problem-​Solving:  Pick Three for at least one item on the task list. ■

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Practice breaking down one large task from the task list into smaller steps. ■ Use the organizational systems developed in this program. ■ Use the distractibility delay when working on boring or unattractive tasks. ■ Use skills to reduce distraction in the homework environment. ■ Put important items in specific places. ■ Use reminders to check in with themselves to see if they have become distracted when trying to focus on completing a task. ■ Read the preceding “Instructions for Completing a Five-​ Column Thought Record.” ■ Write out examples of thoughts on Worksheet 9 for at least two situations during the week. ■



CASE VIGNETTE Therapist: Let’s take a look at one of the thought records you completed this week and see if you can identify a more helpful alternative thought instead of one of your negative thoughts.

Time and situation Wednesday 5:00 p.m.

Automatic thought (Coach A) I’m going to fail the test.

Mood and Thinking intensity trap Worried (80) Jumping to Conclusions

Studying for English test

I haven’t learned Devastated, anything at all Sad (100) this year.

I will never graduate from high school.

All or Nothing Thinking

Embarrassed Catastrophizing (95)

Alternative thought (Coach B) I don’t have any evidence that I am going to fail the test. I have actually been doing pretty well this year. I have learned some things and if I study tonight, I will learn more in time for the test tomorrow. I will graduate from high school if I do my best.

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Therapist: Let’s start with the first thought—​I’m going to fail the test. What evidence do you have that supports or contradicts this thought? Client: Well, I’m worried about this test. I don’t really feel that confident that I know the material. Therapist: Good. Now, even if you don’t get a perfect score on the test, what is the likelihood that you are going to fail it? What’s the evidence you have for that? How many tests have you failed in high school? Client: I don’t think it is really likely that I will fail the test. I actually haven’t failed any tests since I’ve been in high school, and I get worried about failing tests a lot. I’ve been doing pretty well overall this year. Therapist: Great! So the test is likely to be challenging and you might not get a perfect score, but you really don’t have any evidence that you are likely to fail. What about the next thought that you haven’t learned anything this year? Client: As I said, I have been doing pretty well this year. I must have learned some stuff. Therapist: Do you think you might learn more if you study tonight? Client: Probably. That usually works out for me. I often get really upset before tests but then I end up doing fine. Therapist: How about the last thought that you will never graduate from high school? What would you say to a friend if she was having similar thoughts? Client: I would tell her that she always gets worried before tests but there is literally no chance that she won’t graduate. Even if she doesn’t do well on this test, she has a good GPA and she can do some makeup work to bring her average up in this class. Therapist: How would you construct an alternate thought from that? Client: I would say something like—​I will graduate from high school if I do my best. Therapist: Terrific. I understand it’s hard for you when these types of thoughts come up, but I think you can see now how these negative thoughts can really intensify your feelings and make it difficult to problem-​solve and cope with the situation. Client: It’s true. I can really see that now.

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­C HAPTER 10

Session 10: How Can Parents Help? Second Parent/​Adolescent Session

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist

■

Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review homework from previous chapters ■ Review thought records completed during the week ■ Review parent involvement in treatment and troubleshoot any issues or problems ■ Review use of reward system ■ Review changes that the adolescent and family have made as a result of participation in treatment program ■ Review expectations and discuss potential for delayed improvement ■ Identify additional situations that might require adaptive thinking for home practice ■ Evaluate client’s need to complete the optional procrastination session (Chapter 11) ■ Agree on home practice activities and anticipate difficulties using these techniques ■

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Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the adolescent and parent(s) for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda. Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference. Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed. ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​ How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​ Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___​ 128

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Signposts of Change For this session, the signposts of change are:









Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken the task down into smaller steps or completed a problem-​solving worksheet. ■ Client has started to implement a system for decreasing the amount of e-​mail and paper that comes in and needs to be dealt with. ■ Client has identified areas that require an organizational system and has started to implement the system as agreed upon. ■ Client has encountered situations where they needed to concentrate on a boring task and has attempted to use the distractibility delay. ■ Client has identified a home for important items and has started placing the important items in the designated spot on a regular basis. They have shared information about their system with family members. ■ Client has attempted to use strategies for reducing distractibility that were identified in session. ■ Client has started using an alarm to check in with themselves to see if they have become distracted when working on important or difficult tasks. ■ Client has completed a thought record with at least two examples of thoughts that occurred during the week and brought it to the session. ■ Client has attempted to develop rational responses for their thoughts. ■

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Review of Previous Sessions As always, this session includes a review of the client’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties. Repetition of new skills is critical for individuals with ADHD and will maximize gains made in treatment and increase the likelihood of sustaining improvement. Hopefully, at this point, the organization, planning, and distractibility skills will have become automatic for the client. If the adolescent client does not have workable systems established, you should problem-​solve around this issue, perhaps bringing the parent(s) into the discussion. It is unlikely that your client is going to achieve sustainable improvements in their ADHD symptoms if they are not regularly using these skills. As noted previously, it is not necessary that clients use skills perfectly, but it is important that they are attempting to use them. As we note in the preceding signposts of change section, it is a positive sign that the adolescent has made an attempt to develop rational responses. Even if they did not come up with a helpful rational response, you should reinforce their efforts. It is the process of critically evaluating one’s thoughts that is important. You can help the client to refine and improve on their rational responses during the session.

Review: Tools for Organization and Planning



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Use of calendar for managing appointments, meetings, and other commitments: At this point, you should discuss any problems that the adolescent is having using the calendar system. ■ Use of task list: Review any difficulties that the client is having with recording tasks and looking at the task list on a daily basis. ■ Use of the “A,” “B,” and “C” priority ratings: If the adolescent is having any trouble with prioritizing tasks, discuss the difficulties at this point. ■ Use of problem-​solving (selecting an action plan) and breaking down large tasks into small steps: Consider the client’s use of these strategies and practice one or both skills using examples from their current task list. ■

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Review: Tools for Reducing Distractibility



Use of strategy for breaking down boring tasks into manageable chunks: At this point, you should discuss any problems that the adolescent is having breaking down large and/​or boring tasks into manageable chunks. ■ Use of the distractibility delay: Review any difficulties that the client is having with the distractibility delay technique. ■ Use of strategy to remove distractions from the environment. ■ Use of strategy to have a specific place for each important object. ■ Use of reminders or alarms: “Am I doing what I am supposed to be doing?” ■

Review: Tools for Developing Adaptive Thinking



Use of thought records (either on paper or electronically) to identify and label automatic thoughts. Review any difficulties that the adolescent reports with using this strategy. ■ Use of thought record to develop rational responses. Assist the client in developing rational responses if needed. ■

In this session, review the thought records that the client completed at home and discuss any difficulties they may be having with adaptive thinking. If necessary, complete a new thought record to review these skills. If the client has not completed any thought records at home, review the rationale behind homework in cognitive behavior therapy (CBT) with an active discussion emphasizing that, for this treatment, the whole program revolves around doing things differently outside of the sessions. Elicit reasons for resistance and potentially discuss a way forward. Assist the client in problem-​solving around doing home practice.

Review: Parent Involvement in Treatment In this session, revisit the issue of parental involvement in treatment. Ask about any issues that have arisen and how the adolescent and parent(s) have handled them. At this point, you can assist the family 131

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with problem-​solving around these issues if needed. It is possible that the level of parent involvement may need to be adjusted to account for the family’s experiences in therapy thus far.

Review: Reward System During this session, review and revise the reward system that the adolescent and parents worked out at the earlier parent/​adolescent session. Of course, if difficulties have come up in previous weeks, these issues have already been discussed during the parent portion of the adolescent sessions. During this session, conduct a more comprehensive review and problem-​solve to remedy any aspects of the program that aren’t working well. As the end of the treatment program draws closer, the emphasis is on how adolescents and parents will maintain the gains that have been made in the treatment program and on how to make necessary adjustments on their own after the treatment has ended. For example, the reward system that is developed during this treatment may work well with small adjustments through the time that the adolescent finishes high school and leaves for college, but the system will need to be modified when the adolescent comes home for school breaks (or perhaps no longer used once the adolescent is in college).

Review: Behavioral Changes That Adolescent and Family Have Made as a Result of Participation in Program Review all changes/​improvements that the adolescent and parent(s) have made as a result of participating in this treatment. The discussion should focus on how difficult it is to change behaviors and the positive consequences that are likely to result if the changes are maintained over time. Praise both the adolescent and parent(s) for their willingness to engage in the process.

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Review: Parent and Adolescent Expectations and Potential for Delayed Improvement At this point, bring out the list of initial goals for treatment (Worksheet 1: Goals of CBT) and assess how close the adolescent is to reaching the goals set out at the beginning of treatment. You should comment on how realistic these goals were and also discuss the possibility for continued progress toward the goals if the skills learned in the treatment are maintained. Planning for Future Treatment A hearty congratulations to your client is warranted! The adolescent has now completed the core elements of CBT for ADHD. Again review the “problem list” (Worksheet 1) that was completed at the beginning of the treatment to determine whether to begin optional Session 11 (Don’t Put It Off: Stop Procrastinating), to do more review work on sessions that were already completed, or to continue to Session 12 (Keeping It Going). Therapist Note: The skills that have already been taught in this treatment program can be easily applied to the area of procrastination. Potential Pitfalls The adolescent has done a lot of work to get to this point. Clients may feel like taking a break or they may believe that they have done enough work and will no longer have any difficulties related to ADHD. The most important message to emphasize here is that the client needs to Practice, Practice, Practice! This will ensure that newly learned skills become permanent. Your client’s effort will continue to pay off. Practice The adolescent should:

Continue practicing skills learned in previous sessions. Continue to use cognitive techniques for situations involving stress.

■ ■

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Remember to consider any anticipated problems completing the home practice. ■ Implement any changes that client and parents agreed upon to their reward system and other systems. ■

CASE VIGNETTE Therapist: So, I wanted to check in with both of you about how things are going at home. How is it working out, mom, having you remind [Client] to use his strategies? Parent: It is going pretty well, I think. Client: Yeah. It is going ok. Sometimes it feels like my mom is really nagging me to write down my homework assignments in my assignment book from school, but I am glad when I do have them written down so that I know what I need to do for each class. Therapist: So, you are happy to have the information, but sometimes it feels like your mom is nagging you? Client: Yeah. Therapist: Can you think of any better way that she might remind you? Client: I think if she just took my assignment book out of my backpack for me and put it on my desk, it would remind me to check it and make sure that all of my assignments that I have written in other places are on my list for that day. Therapist (to mom): Do you think that this might work out for you? Parent: Sure. I could definitely try that. It really isn’t too much fun for me when we get in an argument either. I will do it starting tomorrow!

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MODULE 4

Additional Skills

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­C HAPTER 11

Session 11: Don’t Put It Off—​Stop Procrastinating

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 10:  Pros and Cons of Procrastination (located in the Appendix) ■ Worksheet 9: Five-​ Column Thought Record (if client is using paper thought records) ■



Session Outline

Set agenda Review ADHD symptom checklist ■ Review progress ■ Discuss the attractive aspects of procrastination ■ Teach adolescent to anticipate the negative consequences of procrastination ■ Use Worksheet 10:  Pros and Cons of Procrastination to determine whether or not to procrastinate ■ Introduce techniques for problem-​solving around procrastination ■ Explain how to use adaptive thinking skills for managing procrastination ■ Agree on home practice activities and anticipate difficulties using these techniques ■ ■

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Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the adolescent and parent(s) for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda. Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference. Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed. ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​ How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​ Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 138

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Signposts of Change For this session, the signposts of change are:









Client is attempting to use calendar and task list systems on a daily basis. ■ Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken the task down into smaller steps or completed a problem-​solving worksheet. ■ Client has started to implement a system for decreasing the amount of e-​mail and paper that comes in and needs to be dealt with. ■ Client has identified areas that require an organizational system and has started to implement the system as agreed upon. ■ Client has encountered situations where they needed to concentrate on a boring task and has attempted to use the distractibility delay. ■ Client has identified a home for important items and has started placing the important items in the designated spot on a regular basis. They have shared information about their system with family members. ■ Client has attempted to use strategies for reducing distractibility that were identified in session. ■ Client has started using an alarm to check in with themselves to see if they have become distracted when working on important or difficult tasks. ■ Client has completed a thought record with at least two examples of thoughts that occurred during the week and brought it to the session. ■ Client has attempted to develop rational responses for their thoughts. ■

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Review of Previous Sessions As always, this session includes a review of the client’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-​ solve around any difficulties.

Review: Tools for Organization and Planning





Use of calendar for managing appointments, meetings, and other commitments: At this point, you should discuss any problems that the adolescent is having using the calendar system. ■ Use of task list: Review any difficulties that the client is having with recording tasks and looking at the task list on a daily basis. ■ Use of the “A,” “B,” and “C” priority ratings: If the adolescent is having any trouble with prioritizing tasks, discuss the difficulties at this point. ■ Use of problem-​ solving (selecting an action plan) and breaking down large tasks into small steps: Consider the client’s use of these strategies and practice one or both skills using examples from their current task list. ■

Review: Tools for Reducing Distractibility



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Use of strategy for breaking down boring tasks into manageable chunks: At this point, you should discuss any problems that the adolescent is having breaking down large and/​or boring tasks into manageable chunks. ■ Use of the distractibility delay: Review any difficulties that the client is having with the distractibility delay technique. ■ Use of strategy to remove distractions from the environment. ■ Use of strategy to have a specific place for each important object. ■ Use of reminders or alarms: “Am I doing what I am supposed to be doing?” ■

 14

Review: Tools for Developing Adaptive Thinking



Use of thought records (either on paper or electronically) to identify and label automatic thoughts. Review any difficulties that the adolescent reports with using this strategy. ■ Use of thought record to develop rational responses. Assist the client in developing rational responses if needed. ■

Introduction to Procrastination Many individuals with ADHD have struggled with procrastination for quite some time, although many do not realize that ADHD can contribute to procrastination. In this session you will review your client’s history with procrastination and try to identify the areas in which it has been most problematic. Some examples might include making phone calls, starting new tasks, applying for jobs, organizing papers, or getting daily projects done. The goals in the session are (1) to help the client identify especially difficult situations that lead to procrastination and (2) to help the client understand the cognitive and emotional factors that contribute to procrastination. Once your client discovers these reasons, they will be able to utilize more effective problem-​solving strategies and decrease the interference of procrastination.

The Attractiveness of Procrastination While procrastination can cause anxiety and anguish, there are also reasons why it seems desirable or easier to postpone tasks. Some reasons are:

Perfectionism or fear of negative evaluation for a less-​than-​perfect product. ■ The idea that it is difficult to get started unless the time pressure is there. ■ The issue seems overwhelming. ■ It is difficult to find a starting point. ■ The tasks requiring sustained effort are not attractive. ■ The thought that it makes sense to wait for a period when there is enough time (this usually never comes). ■

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Ask the adolescent if any of these reasons sound familiar and prompt them to think about the reasons that seem to underlie procrastination for them. Determine if there are any other reasons that are not listed here. The attractiveness of procrastination is not always clear at a conscious level, but if the client thinks about it for a bit, they will recognize some of the common reasons for procrastination.

The Consequences of Procrastination As discussed, procrastination can appear to be a good option for clients if it helps them avoid a negative feeling or if they think that the time/​environment must be just right before they can begin a task. Unfortunately, these potential benefits in the short term are often outweighed by far more negative consequences in the long term. The goal of this section is to emphasize the negative consequences so that they overpower the seemingly attractive aspects of procrastination. Some examples of negative consequences include:





It is stressful waiting until the last minute to complete a task. ■ The task, which is unattractive in the first place, is even worse when it is all-​encompassing. (Waiting until the last minute means that one has to sacrifice other activities as the deadline approaches.) ■ There may be times when clients miss the deadline and there is a penalty (e.g., they get a lower grade on a paper, they are not able to apply to a college for the fall semester). ■ Clients feel worse about themselves later. ■ The final product is not as good as it could have been if the individual had had more time to work on it. ■ Ignoring the problem usually makes it worse and even harder to solve later. ■

Ask the adolescent if they recognize any of these consequences. Have they experienced them? Prompt the client to think about how procrastination has had negative consequences in the course of their life. There may be other negative outcomes that are not listed here but that have been significant for the client.

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Skill: Evaluating the Pros and Cons of Procrastination Sometimes it can be useful to evaluate the pros and cons of an action before making a decision. In this way, “deciding to procrastinate” on a task can be seen as a decision that a client will make. Accordingly, one can use a decisional-​balance style worksheet to help make a decision about what to do. Remember that sometimes the short-​term pros and cons differ from the long-​term, so be sure to evaluate both. Use Worksheet 10: Pros and Cons of Procrastination, found in the Appendix, with the client to objectively rate the pros and cons of procrastination. Unfortunately, it is sometimes difficult for individuals to remember the pros and cons in the moment when they are facing an overwhelming task. Explain that by taking the time now to practice reviewing the pros and cons, they will be better able to remember the consequences in the moment when they are facing procrastination. Ask the adolescent to think of a time when they recently procrastinated. Then ask them to write down the pros and cons of procrastination in the short term. After this, ask them to write down the pros and cons of procrastination in the long term. Spend a few minutes with the client to reflect on their answers. Generally, we see a pattern where there are more pros for procrastination in the short term and more cons for procrastination in the long term. Discuss how the client might bring that long-​ term con box into their decision-​making process around procrastination moving forward.

Skill: Adapting Problem-​Solving to the Issue of Procrastination In Session 4 of treatment, we introduced skills for problem-​ solving. When a task feels overwhelming, or a client is uncertain about where to begin, they are more likely to procrastinate. Using a problem-​solving worksheet and/​or breaking the task down into manageable steps will help avoid this.

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If the adolescent is procrastinating around completing a specific task, instruct them to ask themselves, “Am I  procrastinating because I don’t know what to do?” If the answer to this question is “yes,” they should complete a problem-​solving worksheet (from Chapter 4; see Worksheets 3 and 4, located in the Appendix) to try to figure out the best solution to the problem. If the answer to this question is “no,” they should then ask themselves, “Does the task feel too overwhelming?” If the answer to this question is “yes,” they should use the breaking down large tasks into manageable steps skill (see Worksheet 5, located in the Appendix), also discussed in Chapter 4. Remind your client that each step should feel completely doable. Ask them to do a “gut check.” The gut response should be that the task feels absolutely doable in one day. If it doesn’t, the client should break down the step further. Alternatively, rather than attempting to work on the whole problem, they may want to target only one or two sub-​goals. Another trap is to set unreasonable goals. Remind the adolescent that each step should be realistic. The skills learned for managing distractibility will also be useful here. If your client knows that they can typically only work on unpleasant tasks for 15 minutes, then break down each step into goals that can be completed within this time frame. Review: Breaking Down Large Tasks into Manageable Steps: 1. Choose a difficult or complex task from the master task list. List the steps that must be completed. This can be done on paper or electronically. Ask questions such as, “What is the first thing that I would need to do to make this happen?” 2. For each step, make sure that it is manageable. Have the adolescent ask themselves, “Is this something that I  could realistically complete in one day?” and “Is this something that I  would want to put off doing?” If the step itself is overwhelming, then that step should be broken down into even smaller steps. 3. List each individual step on the daily task list.

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Skill: Using Adaptive Thinking to Help with Procrastination In the section on self-​coaching (Sessions 8–​9), adolescents learned that their thoughts can play a powerful role in how they feel about situations and that thoughts can influence their actions. Negative automatic thoughts can also greatly contribute to procrastination. Using thought records (e.g., Worksheet 9: Five-​Column Thought Record, located in the Appendix) will help clients create balanced, helpful thoughts that will decrease procrastination. Review: The Steps for Completing a Thought Record Remind your client about the steps to completing the thought record.

1. List the situation contributing to procrastination. 2. List the automatic thoughts regarding the task or goal (Coach A thoughts). 3. Refer to the list of thinking errors to evaluate their thoughts. 4. Formulate rational responses to these thoughts (Coach B thoughts). Example As we’ve emphasized throughout the manual, practicing new skills is essential if adolescents are to ultimately be able to use them easily in a given situation. Here is an example of how to use a combination of all the skills to help with procrastination (breaking down the task, putting steps on the list, and using the worksheet to identify thoughts that might be getting in the way of starting the first step).



Ask your client to think about a specific task or issue about which they have been procrastinating. ■ Assist the adolescent in using each of the preceding skills for this task or issue. ■ Use problem-​ solving to help break down the task into manageable steps. ■ Instruct the client to write down the steps on their master task list. ■

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Using Worksheet 9:  Five-​Column Thought Record, assist the adolescent in listing the automatic thoughts they are having about getting started. ■ Finally, prompt the client to identify the appropriate thinking errors and come up with helpful, rational responses. ■



Potential Pitfalls Although clients may have struggled with procrastination for many years, it is important to remind them that they can use the strategies they have learned to decrease the interference of procrastination. Even if they are unsure about whether these strategies will help, encourage clients to do an experiment. Instruct them to commit to using these skills each day for 1 month and see how well they do. Chances are they are going to see the results quickly, and it will then be easier to practice the newly learned techniques.

Practice The adolescent should:



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Plan a reasonable goal or two to start, from the list of steps they have outlined on their master task list. ■ Think of a way they can reward themselves upon completion of the goals. They might want to set up rewards for intermediate steps toward their goals to help keep them motivated (e.g., give themselves a small reward for each paragraph or page that they write and a larger reward when the paper is done). ■ Review use of skills from the previous sessions of treatment. They should be sure to write down any questions or difficulties they may be having so that they can discuss them with you at the final session. ■

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CASE VIGNETTE Therapist: Would it be ok if we were to talk about how procrastination plays out for you and talk about the pros and cons? Client: Ok. Therapist: Great. Let’s start with the short-​term pros of procrastination. Client: Well, I don’t have to do the task I’m trying to avoid. Therapist: True. What else? Client: I can do something more fun, like go out with my friends or play video games. Therapist: I see. There are more enjoyable, attractive activities that you’d rather be doing. What are some of the long-​term pros? Client: Hmmm. I’m not sure I can think of any, other than what I’ve already mentioned. So the short-​term pros are also the long-​term  pros. Therapist: Isn’t that interesting? How about the short-​term cons? Client: I always feel guilty and anxious when I know there is something I need to do and I am avoiding doing it. That makes me feel tense and then I usually get a migraine and become really irritable. My girlfriend hates when I get like that, and she sometimes says that she won’t see me until I finish whatever I need to do—​so I’ll stop being so grouchy. Therapist: So, even though it seems that you get to do more enjoyable activities when you’re not doing the avoided tasks, you really suffer emotionally and physically, and you aren’t able to spend as much time with your girlfriend as you could. What about the long-​term consequences? Client: One time, a different girlfriend broke up with me because I was always so irritable, and she knew it was because I was procrastinating. I  guess I’ve also had problems at school. I usually wait until a few days before a paper is due to start working on it. By the time I have an outline or a rough draft, it is usually too late to talk with the teacher to get feedback and help. I’ve always been a C student, but if I started papers and projects a little earlier, I’d easily get at least a B.

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Therapist: That’s too bad. Your relationships and school performance have really suffered. What do you realize when you really examine the short-​and long-​term pros and cons? Client: Of course it’s obvious! Procrastination creates more problems than it solves. If I could make some small changes it could easily get better. Therapist: You’re exactly right! Using the problem-​solving skills can make it so much easier to complete tasks and avoid the cycle of procrastination. Why don’t you do an experiment this week and see what happens when you use these skills? Client: Ok.

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­C HAPTER 12

Session 12: Keeping It Going

Materials Needed

Attention-​deficit/​hyperactivity disorder (ADHD) symptom checklist ■ Worksheet 11:  Treatment Strategies and Usefulness, located in the Appendix ■ Worksheet 12: One-​Month Review, also located in the Appendix ■



Session Outline

Set agenda ■ Review ADHD symptom checklist ■ Review Worksheet 11: Treatment Strategies and Usefulness ■ Discuss maintenance of gains and use of Worksheet 12: One-​Month Review ■ Discussion of troubleshooting using Figure 12.2 ■

Set Agenda It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda.

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Review of Symptom Checklist Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference. Review of Medication Adherence Give the client a copy of the ADHD Medication Form to complete at the start of the session. Review the form and talk with the adolescent about any discrepancies between the number of medication doses that were prescribed and the number of doses that the adolescent actually took. Discuss reasons for missed doses such as being distracted, running out of medication, parents forgetting to give the adolescent their medication, or the adolescent having thoughts about not wanting/​needing to take medication. Make a plan to address any issues that prevented the adolescent from taking their medication as prescribed. ADHD Medication Form How many times were you supposed to take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

How many times did you actually take your ADHD medicine this week? _​_​_​_​_​_​_​_​_​_​_​_​_​_​

Reasons for missed doses: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ ​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​ Signposts of Change For this session, the signposts of change are: 150

Client is attempting to use calendar and task list systems on a daily basis.

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Client is putting all tasks that need to be completed on master task list. ■ Client has identified a consistent time and place for looking at their calendar and creating daily task list. ■ Client is using priority ratings for daily task list. ■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken the task down into smaller steps or completed a problem-​solving worksheet. ■ Client has started to implement a system for decreasing the amount of e-​mail and paper that comes in and needs to be dealt with. ■ Client has identified areas that require an organizational system and has started to implement the system as agreed upon. ■ Client has encountered situations where they needed to concentrate on a boring task and has attempted to use the distractibility delay. ■ Client has identified a home for important items and has started placing the important items in the designated spot on a regular basis. They have shared information about their system with family members. ■ Client has attempted to use strategies for reducing distractibility that were identified in session. ■ Client has started using an alarm to check in with themselves to see if they have become distracted when working on important or difficult tasks. ■ Client has completed a thought record with at least two examples of thoughts that occurred during the week and brought it to the session. ■ Client has attempted to develop rational responses for their thoughts. ■ Client has noted instances where they are procrastinating and has attempted to use strategies to address this. ■

Ending Treatment and Maintaining Gains The key to successful termination and relapse prevention for individuals with ADHD is persistent use of the skills they have been taught during treatment. We recommend overemphasizing this point with adolescents.

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Most of our clients hear the following phrase in almost every treatment session as well as in the follow-​up sessions: The strategies and skills need to be practiced regularly so that they become more and more automatic and therefore take less and less effort. In other words, the end of regular sessions of treatment signifies the starting point of the client’s own program of treatment, where they work to lock in and extend the skills and strategies that they have learned. To help adolescents transition to this next phase of treatment—​where they take over the role of the therapist—​it is important for them to recognize the nature of any benefits they have achieved. One way to look at progress is to graph or make a table of the ADHD rating scale scores from each week of the program with the client in the session. Copy Figure 12.1: Symptom Checklist Scores and complete it

Figure 12.1 Symptom checklist scores. 152

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with your client. If there are “sudden gains” in treatment—​dramatic or significant reductions in a score on a given week—​it is important to discuss what occurred that week that caused the change (i.e., they finally started using a calendar to track appointments, they started looking at the task list daily).

Examining What Was Valuable In addition to attempting to recall which sessions had the most gains, we review the treatment strategies and determine how useful they are. Worksheet 11:  Treatment Strategies and Usefulness is also in the Appendix of the Client Workbook and can be done at home prior to this session—​and discussed in the session—​or it can be completed and discussed in the session. As the discussion progresses, provide positive feedback regarding the approaches that worked and emphasize the importance of continuing to use them. If there are strategies that have not worked, these do not need to be continued. However, you should also problem-​solve any difficulties (e.g., if any strategies that were useful in the past are no longer being used or if any are not being used consistently).

Maintaining Gains An important distinction for adolescents to be aware of is the difference between a setback and a relapse. A setback refers to an instance when the client has some difficulties with symptoms, whereas a relapse refers to the person being back to where they started, as if they had never done any treatment. We consider setbacks to be a normal and expected part of progress. Successful treatment does not mean that clients will have no future difficulties with symptoms. For most conditions, symptoms can wax and wane over time. Stress the idea that the key to maintaining treatment gains over the long run is to be prepared for periods of increased difficulties. Explain that these periods are not signs that the treatment has failed. Instead, these periods are signals that the client needs to apply the skills learned in treatment. The adolescent can use Worksheet 12: One-​Month Review, 153

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to refresh skills as needed. The purpose of the worksheet is to remind the client of the importance of practicing skills and to think through which strategies might be important to practice. Talk with the adolescent about scheduling a review session on their own. Discuss using the calendar to pick a time and date approximately 1 month after the final treatment session. The client should sit down with Worksheet 12 and complete it as if they are having an actual therapy session. If the client is not able to get back on track themselves, they may wish to schedule a “booster session” with you to review skills and get a tune-​up to help with maintaining and generalizing skills. During this final session, talk with the adolescent about the role that parents can play in maintaining treatment gains. You can discuss ideas about how parents might support skills use or point out when a booster session might be helpful. These suggestions can be discussed with parents at the end of the session so that everyone is on the same page about the plan going forward.

Troubleshooting Difficulties It may also be helpful to match some of the symptoms the adolescent is experiencing with some of the specific strategies used in treatment. Use Figure 12.2 to help the client match specific symptoms with skills that were taught in the treatment sessions. Finally, you may want to suggest that the client use the problem-​solving worksheets in Chapter 4 (Worksheets 3 and 4) to more carefully consider any difficulties with symptoms. Suggest that the client enlist the help of family and friends and/​or schedule a booster session with you if the preceding strategies are not effective in reducing the adolescent’s ADHD symptoms. Booster sessions are common in cognitive behavioral therapy (CBT) and should not be viewed as a sign of failure. Rather, booster sessions are an opportunity to review skills and troubleshoot difficulties. In our research trials, we did not include booster sessions. However, in clinical practice, it is common for us to see a client for a course of CBT and then continue to have infrequent booster sessions over a period of up to

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Figure 12.2 Troubleshooting difficulties chart.

one year or longer. Many clients report that they find the booster sessions helpful in maintaining the gains that they have made in CBT.

Termination As with any therapy, spend some time processing termination with the adolescent. Share your thoughts about how it was for you to work with the client, noting aspects of the treatment that were especially enjoyable for you (i.e., “I know you really had doubts about being able to keep track of all of your homework, and it was a pleasure for me to watch you work through that and get to the point now where you can’t imagine not making a list of your homework for each day and prioritizing it.” )

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Congratulate the client for all the hard work that was put into completing this treatment program. It was demanding! However, we truly believe these skills can make a profound difference and help reduce the severity of ADHD symptoms. Remind the client one final time that they need to practice, practice, practice the skills they learned. Improvements will not magically maintain themselves. Only through continued use will skills become automatic.

CASE VIGNETTE Therapist: Today is our last official session. I wanted to spend some time talking about how you can keep going with using your skills on your own. Does that sound ok? Client: Sure. Therapist: Excellent. First, I just want to congratulate you on all the hard work that you have done. Client: Thanks. It has been hard at times. Therapist: Of course it has. I  think you have made some great progress, and you now have some tools that you can use to help you stay organized. It may not always be smooth sailing though—​you may have times when you notice that your symptoms seem to “flare up.” You shouldn’t get too upset when this happens because it is totally normal. It is just a sign that you need to take a step back and figure out what tools you can use. We have a few things that can help with this. Client: Ok. Like what? Therapist: Good question. One thing that might be helpful for you to look at is Worksheet 11:  Treatment Strategies and Usefulness. We are going to fill this out today, and you can go back and look at it on your own. You can also refer back to Figure 12.2 in the Client Workbook, which is a troubleshooting guide—​sort of like the thing that you get when you buy a new electronic device. It gives you suggestions for things that you can try if you are experiencing various symptoms. I am also going to suggest that you schedule some review sessions on your own. You might do this at the same time and day that we have been meeting. This is a good time for you to review how things have been going with your

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ADHD symptoms and think about what skills you need to work on. Why don’t you schedule one for about a month from now? Client: I can try that, but what if I am still having trouble? Therapist: You can always call me and ask to schedule a booster session. This would be a session where we check in and sort of do a “tune-​up” on your skills and talk about what you need to keep working on. This is a normal part of this treatment and is not a sign of trouble or failure. Client: That sounds good. I’m happy to know that is an option. Therapist: Of course. It has been so great working with you and so nice to see all the progress that you have made. Please don’t hesitate to call if you have any questions or want to come in for a booster session in the future. Client: Thank you!

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MODULE 5

Optional Coaching Sessions for Parents Without the Adolescent Present

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CHAPTER 13

Session 13: Parent Coaching Session 1: Between Adolescent Sessions  3–​5

Therapist Note: This session can take place at any time in the early part of the treatment program, typically one or two sessions after the first parent/​adolescent session. It is held either at the request of the parent or if the therapist feels that it would be helpful to have discussions with the parent(s) without the adolescent present. The primary goals are to provide information about the treatment to the parents and to make sure that they are going to be supportive of the client. You can use your clinical judgment and work around the schedules of your client’s parents in deciding when to schedule this session.

Session Outline



Set agenda Assess parent motivation for and hopefulness about cognitive behavioral therapy (CBT) in helping their adolescent with attention-​ deficit/​hyperactivity disorder (ADHD) ■ Conduct motivational interviewing with parent if needed ■ Discuss services that the adolescent is currently receiving at school (if applicable) ■ Assess whether other services or interventions are needed and coach parents on how to obtain these services ■ Assess how the contingency management system is working ■ Problem-​solve around issues with the contingency management  system ■ Discuss limit-​setting with adolescents and review parenting style ■ Agree on home practice activities and anticipate difficulties using these techniques ■ ■

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Set Agenda It is important to begin each session by setting an agenda. Review the session outline with the parents. The parent sessions are less structured than the adolescent-​only sessions and the parent/​adolescent sessions by design in order to give parents and the therapist the opportunity to bring up topics of concern. It is useful for parents to have this opportunity to air any concerns during this session when the adolescent is not present so that parents are not expressing their concerns in front of the adolescent, which can create friction in the family and perhaps interfere with the adolescent’s willingness to participate in treatment.

Assess Parent Motivation and Hopefulness The goal of this portion of the session is to assess parent motivation for change and level of hopefulness that their adolescent can improve. As noted in other chapters in this Therapist Guide, parents can become frustrated with their adolescent’s behaviors and often convey this to the adolescent, which can interfere with the adolescent’s motivation. Also, this treatment program requires parent involvement to facilitate adolescent improvement. Some of this involvement necessitates behavioral changes on the part of the parents. For example, if the family is implementing weekly family meetings to facilitate communication about schedules, this requires not only that the adolescent attend the meeting, but also that the parents make time in their schedules for the meeting. Another example would be the use of the contingency management system: once the system is developed, parents need to monitor progress and reliably provide the agreed-​upon rewards if the system is to be useful.

Validate Parent Experience Another discussion point can be to validate the experience of the parent(s). They may know other parents who have kids who just do their work and do it well without much help or reminders. It can be frustrating and upsetting for parents of children and adolescents with ADHD when the parents need to put so much effort into getting their

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kids to do their schoolwork. At the time of adolescence, it is particularly important to try to get children to transition from having a lot of parent involvement in homework and schoolwork to having more autonomy. But, the flip side of this is that with less parental involvement in monitoring and doing homework with their child, sometimes the work doesn’t get completed and problems arise. Spend some time in the sessions validating the parent’s experience, asking about the difficulties that they have had and the strategies that they have tried, and then help them develop realistic expectations about their children.

Conduct Motivational Interviewing with Parent(s) If parent motivation appears to be low and/​or if the parents indicate they are not hopeful that the adolescent can improve, conduct motivational interviewing at this juncture. You can talk with the parents about obstacles to change, validate the challenges, and then see if you can get the parents to engage in “change talk.” Generally, parents agree that the adolescent’s behaviors need to change, but they sometimes fail to see that they themselves may need to change something about what they are doing in order to facilitate behavior change in the adolescent.

Discuss Services That Adolescent Is Receiving at School Discuss current services with parent(s). This should include an assessment of the services that the adolescent is currently receiving. Inquire about the presence of an Individualized Education Program (IEP) or 504 Plan. If there is a plan in place, inquire about the specific accommodations that are listed in the plan and ask the parent to provide a copy of the plan. You can ask about remaining problems that are not addressed in the plan and make suggestions for other elements that the parents could request (e.g., more frequent communication from teachers, double sets of books for home and for school, and reduced homework volume). There is some controversy in the field about the extent of accommodations that is desirable for adolescents with ADHD. While it can be useful to

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have some accommodations, there is concern that if adolescents have too many accommodations, they will not learn the needed skills to be effective in college, the workplace, and other areas of their lives. Discuss this issue with parents at this session. If it does seem that additional services would be helpful, coach the parents on steps that they can take to advocate for their child to obtain these services.

Assessment of Contingency Management System The concept of using a contingency management system will have been discussed at the recent parent/​adolescent session, and the system should have been implemented by the time of this session. The system can be reviewed with the parents, and problem-​solving can occur around any issues that have come up.

Limit-​Setting and Parenting Style Discuss parenting style and encourage parents to look at their own parenting style. Ask them to consider which strategies are working well for them and which strategies are ineffective. It is important to do this in a nonjudgmental manner as this can be a difficult topic for many parents. Parents of adolescents with ADHD often perceive that they are working very hard to help their children and can get frustrated when they do not feel that their efforts are working. It is imperative that, as the therapist, you demonstrate an understanding of these issues yet gently prompt parents to look at their behaviors in order to start moving toward a more effective parenting style. If parents discuss any difficulties with setting limits with their adolescent (or if you have observed this in the sessions), this can be discussed, and parent attitudes and beliefs about this can be examined. The concept of parenting styles was first described by Baumrind in the 1960s (Baumrind, 1966)  and then expanded by Maccoby and Martin (1983). The four parenting styles are authoritative, authoritarian, permissive, and uninvolved. Research has demonstrated that authoritative parents are typically the most effective.

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Discussion Point: Lying You should bring up the issue of lying. Often, when adolescents with ADHD are asked questions such as “Are you finished with your homework?” “Do you have any math homework today?” “Did you put your laundry away yet?” they will respond quickly with the answer that will get the parents to stop “bugging” them. At times, parents will label this behavior as “lying,” and it will cause arguments within the family. At this point, you should normalize this behavior in adolescents with ADHD (and adolescents, in general) and suggest an alternate name for the behavior. You can ask the parent(s) to consider alternate reasons why the adolescent may engage in the behavior. Try to guide the parent(s) toward reasons that are less extreme and less likely to provoke an extremely negative emotional reaction from the parent (e.g., the adolescent is intentionally trying to deceive the parent or the adolescent is a sociopath who is ultimately going to end up in prison). Reasons could include feeling overwhelmed by homework and wanting to deal with it later, wanting to relax at the end of the day, and thinking that they will get to it later. Explain that individuals with ADHD often tell themselves that they will do something later, and they really, truly mean it when they are telling themselves this. The problem is that often they get distracted, they underestimate the time that it will take to do things, and it doesn’t get done. Encourage parents to think about how changing the way that they view and respond to this behavior can improve communication with their adolescent with ADHD and ultimately improve outcomes.

Potential Pitfalls Parents may feel as if they are doing their best already and feel defensive about any attempts on your part to suggest that there is something about their behavior that needs to be changed. Try to balance validating the parent’s perspective that they are trying very hard with pointing out that some of the strategies don’t seem to be working well.

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Practice

The parents will leave this session with some specific things that they need to work on. These could include (1)  speaking with the adolescent’s school about accommodations, (2)  modifying the contingency management system, or (3) reacting to the adolescent in a different, more effective manner.

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CASE VIGNETTE Therapist: Thanks for coming in today. I  thought it might be helpful for us to have a discussion about the therapy so far and any issues you are concerned about. Parent: Yes. I’m glad to have a chance to talk to you without my son present. I  just get so frustrated with him. I  hear my friends talk about their kids, and it seems like they just come home and do their homework without any problem. With Sammy, it is always a big struggle to get him to do his homework and we end up arguing a lot. Therapist: I know. This can be really, really frustrating for both parents and adolescents with ADHD. Parent: I never even know if he’s telling me the truth about what he needs to do. I ask him if he has homework for a certain class, and he tells me that he doesn’t have any or he finished it in school, and then we sometimes get mid-​term warnings saying that he is missing tons of homework and is getting a bad grade. I just can’t take the lying anymore! Therapist: That can definitely be upsetting as a parent. Do you have any ideas why he doesn’t tell you the truth about his homework? Parent: Well, Sammy is usually pretty honest about his English homework and his science homework—​the subjects that he likes. It is mostly his math homework that he rushes through or doesn’t complete. I  think math is really challenging for him so it is unpleasant for him to sit down and try to figure it out. Often, he would much rather get out and go see friends, get on his phone or computer, watch TV, or do almost anything else.

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Therapist: So when you think about it that way, does it seem like he is lying for the sake of lying, or does it make more sense? Parent: I guess it makes more sense. Therapist: Do you think it is helpful when you label the behavior as “lying” when you think about it in your head and when you discuss it with your son? Parent: Not at all. It gets me upset and makes me angrier, and my son gets defensive and shuts down when I  accuse him of lying. Therapist: I wonder if you could come up with a different name for the behavior that might be less inflammatory? Parent: I’ll need to think about it, but that makes sense. Therapist: That being said, the behavior definitely seems problematic. I wonder if we could figure out a way to reward Sammy for being transparent about his homework assignments, maybe find a way to verify assignments with the teacher or the school web site and start to build trust. Parent: That seems like it might work.

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CHAPTER 14

Session 14: Parent Coaching Session 2: Between Adolescent Sessions  7–​9

Therapist Note: This session can take place at any time in the later part of the treatment program, typically just before the second parent/​adolescent session. It is held either at the request of the parent or if the therapist feels that it would be helpful to have discussions with the parent(s) without the adolescent client present. The primary goals of this session are to follow-​ up on parent goals, to make sure the contingency management system is working well, and to address any remaining concerns that parents might have. Use your clinical judgment and work around the schedules of your client’s parents in deciding when to schedule this session.

Session Outline

Set agenda ■ Review parent goals and progress ■ Check in on use of contingency management system ■ Check in on status of school accommodations ■ Identify areas for continued improvement ■ Develop a game plan to address areas for continued improvement ■ Agree on home practice activities and anticipate difficulties using these techniques ■

Set Agenda It is important to begin each session by setting an agenda. Review the preceding session outline with the parents. The parent sessions are less structured than the adolescent-​only sessions and the parent/​adolescent

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sessions by design in order to give parents and the therapist the opportunity to bring up topics of concern. It is useful for parents to have this opportunity to air any concerns during this session when the adolescent is not present so that parents are not expressing their concerns in front of the adolescent, which can create friction in the family and perhaps interfere with the adolescent’s willingness to participate in treatment.

Review of Parent Goals Bring out the list of goals that the parent identified in the first parent/​ adolescent session (Worksheet 1: Goals of CBT-​Parent Version). Review these goals with the parent and discuss progress that has been made toward these goals. Start off by letting the parents know about positive changes that you have noticed in the adolescent. You can then ask the parents to comment on the improvements that they themselves have observed. You can also comment on the positive changes that you have noticed in interactions between the parent and their adolescent. You should validate how difficult it can be to focus on the positive and reinforce the importance of doing this.

Review of Parent Experience You should also check in with the parents about their personal experience and how the parenting relationship is affecting them. It is important for parents to have realistic expectations about what their child will be able to do, and this can be upsetting for some parents who might place higher demands on their kids. Now that you have a better sense of the adolescent client’s abilities, this is a good opportunity for you and the parents to discuss what additional gains can be expected and set realistic expectations about what inputs from the parent are likely to be effective for both parties (parent and child).

Check In on Contingency Management System At this point in treatment, the family should have been using the contingency management system for several months. You can ask the parents 170

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how the system is working from their perspective, problem-​solve around any issues that have come up, and discuss how the family can continue using the system moving forward. This is an area where the discussion might look quite different depending on the age of the adolescent. As adolescents get older and become increasingly independent, the rewards may evolve and change, and parents may take a less active role in monitoring and administering the system. While it might be perfectly acceptable for the parent of a middle school student to review progress on a daily basis and provide trips to the mall or new video games on the weekends, the parents of a college student would not be likely to use a contingency management system in the same way.

Check In on School Accommodations If the parents identified any school accommodations that they would like to seek at the last parent-​only session, check in with them about the status of these accommodations. Conduct problem-​solving if the parents have encountered any obstacles to obtaining the accommodations they are seeking for their adolescent.

Identify Areas for Continued Improvement and Develop Game Plan to Address These Areas Talk with parents about any areas where continued improvement is needed. You should continue to emphasize the importance of setting realistic expectations (e.g., if the adolescent with ADHD has severe learning disabilities and has been turning in homework assignments, completing chores, etc., but is still not achieving straight As, the parents could be encouraged to examine their expectations of straight As for their child). You can use the Worksheet 3:  Problem-​Solving:  Selection of Action Plan format to look at solutions to address the remaining areas where continued improvement is needed. This will help both you and the parents to work toward a solution in a structured manner and give the parents a concrete example of how problem-​solving skills can be implemented. 171

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Potential Pitfalls Parents may have unrealistic expectations for the treatment and for their child. In this case, they may use this session as a forum for venting about their distress. It will be helpful for you to use the structure of the treatment to emphasize the progress that has been made thus far and to talk about the fact that the adolescent can continue to use their skills to attain further improvement, even after the formal treatment sessions have ended.

Practice

Parents will implement the agreed-​upon solutions to address remaining areas where improvement is needed.

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CASE VIGNETTE Therapist: I just wanted to check in with you about how you think your daughter is doing with working toward the goals that we had outlined when she started this treatment. Would that be ok? Parent: Yes, thanks. I think she is doing ok. She is definitely keeping track of her assignments better, and her room is not as messy. I  feel that we have been having fewer arguments at home since we have been working on having a family calendar so there are fewer opportunities for miscommunications. Therapist: Well, that all sounds promising! Parent: I don’t know though. She just isn’t doing as well as I had hoped. I thought that once we got this organizational stuff sorted out, she would start doing really well in her classes, and we could finally start thinking about sending her to a top-​tier college. Therapist: From what you know of your daughter, how realistic is that?

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Parent: Not really. We had her go through neuropsychological testing a couple of years ago, and it showed that she has some learning issues. Also, she doesn’t seem to really thrive in high-​ intensity academic situations. Therapist: What do you want for your daughter in the long run? Parent: I really just want her to be able to function well—​have good relationships, have a job that she enjoys and that will allow her to support herself in a comfortable manner. Therapist: Do you think she will be able to do that even if she doesn’t go to a top-​tier college? Parent: Yes. Definitely. I guess I should focus on the good work that she is doing and not get too fixated on the things that she isn’t doing.

 

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Appendix

Clients will need to complete some of the worksheets in this Appendix multiple times throughout this treatment program. Either you can provide the copies for clients, or they can download blank copies themselves from the TreatmentsThatWork™ website at www.oup.com/​adolescentADHD.

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Worksheet 1

Goals of Cognitive Behavioral Therapy (CBT)

Goal of CBT

Controllability (as a percent)

Short or long term

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Worksheet 2

Task List Priority rating

Task

Date put on list

Date completed

A A . . B . . . . . . C . . . . . . Note: This format can be used for a paper system. Many electronic systems allow for making priority ratings as well. You should use the system that best fits your needs.

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Worksheet 3

Problem-​Solving: Selection of Action Plan Statement of the problem: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​______​_​_​_​_​_​_​_​_​_​_​_​_​_ ​ Instructions for chart:

1. List all of the possible solutions that you can think of. List them even if you think they don’t make sense or you don’t think you would do them. The point is to come up with as many solutions as possible. 2. List the pros and cons of each solution. 3. After listing the pros and cons of each, review the whole list, and give a rating to each solution. 4. Use additional copies of this sheet as needed (even if it’s for the same problem).

Possible solution

Pros of solution

Overall rating Cons of solution of solution (1–​10)

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Worksheet 4

Problem-​Solving: Pick Three Description of problem:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Possible solution Pros of solution

Cons of solution

Rating

“Winning” solution_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Worksheet 5

Problem-​Solving: Small Steps Description of large task:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

What is the first small step?

What is the second small step?

What is the third small step?

What is the fourth small step?

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Worksheet 6

Strategies for Reducing Distractions Distraction

Distraction reduction strategy

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Worksheet 7

Three-​Column Thought Record Time and situation

Automatic thoughts

Mood and intensity

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Worksheet 8

Four-​Column Thought Record Time and situation

Automatic thoughts

Mood and intensity

Thinking trap

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Worksheet 9

Five–​Column Thought Record Time and situation

Automatic thought (Coach A)

Mood and intensity

Thinking trap

Alternative thought (Coach B)

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Worksheet 10

Pros and Cons of Procrastination Short term

Long term

Pros

Cons

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Worksheet 11

Treatment Strategies and Usefulness Please rate the usefulness of each strategy to you (0 “Didn’t help at all” to 100 “Was extremely important for me”). Also, take some time to provide notes to yourself about why you think each strategy worked or didn’t work for you, and decide which strategies might be most helpful for you to practice over the next month.

Treatment strategies

Usefulness ratings

Notes about your application/​ usefulness of the strategy

Review: Tools for Organization and Planning: ■ Calendar for managing your schedule ■ Task list system ■ Priority ratings ■ Problem-​solving (selecting an action plan) ■ Breaking down large tasks into small steps ■ Rewards to increase motivation to complete tasks ■ Organizational systems Review: Strategies for Managing Distractibility: ■ Breaking tasks down into manageable chunks and use of breaks in between tasks ■ Distractibility delay ■ Removing distractions from the environment ■ Having specific places for important objects ■ Reminders/​Alarms—​“Am I doing what I’m supposed to be doing?” Review: Adaptive Thinking: ■ Writing down negative/​unhelpful thoughts ■ Reviewing list of thinking traps ■ Using Coach B thinking to create balanced, helpful thoughts 197

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Worksheet 12

One-​Month Review Date of review: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 1. What skills have you been practicing well?

2. Where do you still have troubles?

3. Can you place the troubles in one of the specific areas used in this treatment?

4. Have you reviewed the skills most relevant to your difficulties? (Which skills are these?)

5. Have you reviewed Worksheet 11: Treatment Strategies and Usefulness, where you wrote those skills that were most helpful to you in the first phase of this treatment? Do you need to reapply these skills or strategies?

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References

Adler, L. A., & Chua, H. C. (2002). Management of ADHD in adults. Journal of Clinical Psychiatry, 63(supp. 12),  29–​35. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC:  American Psychiatric Association. Arnold, L. E., Hodgkins, P., Caci, H., Kahle, J., & Young, S. (2015). Effect of treatment modality on long-​term outcomes in attention-​deficit/​hyperactivity disorder: A systematic review. PLoS One, 10(2). Barkley, R. A. (1977). A review of stimulant drug research with hyperactive children. Journal of Child Psychology and Psychiatry, 18, 137–​165. Barkley, R. A., Fischer, M., Edelbrock, C. S., & Smallish, L. (1990). The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-​year prospective follow-​up study. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 546–​557. Barkley, R. A., Fischer, M., Edelbrock, C. S., & Smallish, L. (1990). The adolescent outcome of hyperactive children diagnosed by research criteria, III: Mother-​child interactions, family conflicts and maternal psychopathology. Journal of Child Psychology and Psychiatry, 32, 233–​255. Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2004). Young adult follow-​up of hyperactive children:  Antisocial activities and drug use. Journal of Child Psychology and Psychiatry, 45, 195–​211. Barkley, R. A., & Murphy, K. R. (1998). Attention-​deficit hyperactivity disorder: A clinical workbook (2nd ed.). New York: Guilford. Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford. Baumrind, D. (1966). Effects of authoritative parental control on child behavior. Child Development, 37(4), 887–​907. Biederman, J., Faraone, S. V., Keenan, K., Benjamin, J., Krifcher, B., Moore, C., . . . Tsuang, M. T. (1992). Further evidence for family genetic risk factors in attention deficit hyperactivity disorder:  Patterns of comorbidity in probands and relatives in psychiatrically and pediatrically referred samples. Archives of General Psychiatry, 49, 728–​738.

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20

Biederman, J., Faraone, S. V., Keenan, K., Steingard, R., & Tsuang, M. T. (1991). Familial association between attention deficit disorder and anxiety disorders. American Journal of Psychiatry, 148, 251–​256. Biederman, J., Munir, K., Knee, D., Armentano, M., Autor, S., Waternaux, C., & Tsuang, M. (1987). High rate of affective disorders in probands with attention deficit disorder and in their relatives: A controlled family study. American Journal of Psychiatry, 144, 330–​333. Biederman, J., Munir, K., Knee, D., Habelow, W., Armentano, M., Autor, S., . . . Watermaux, C. (1986). A family study of patients with attention deficit disorder and normal controls. Journal of Psychiatric Research, 20, 263–​274. Biederman, J., Petty, C. R., Evans, M., Small, J., & Farone, S. V. (2010). How persistent is ADHD? A controlled 10-​year follow-​up study of boys with ADHD, Psychiatry Research, 177, 299–​304. Cantwell, D. P. (1972). Psychiatric illness in the families of hyperactive children. Archives of General Psychiatry, 27, 414–​417. Centers for Disease Control and Prevention (CDC). (2010). Increasing prevalence of parent-​reported attention-​deficit/​hyperactivity disorder among children:  United States, 2003 and 2007. MMWR. Morbidity and Mortality Weekly Report, 59(44), 1439–​1443. Chronis, A. M., Jones, H. A., & Raggi, V. L. (2006). Evidence-​based psychosocial treatments for children and adolescents with attention-​deficit/​ hyperactivity disorder. Clinical Psychology Review, 26, 486–​502. Craske, M. G., Barlow, D. H., & Meadows, E. A. (2000). Mastery of your anxiety and panic (MAP-​3). Boston: Graywind. Cuffe, S. P., McKeown, R. E., Jackson, K. L., Addy, C. L., Abramson, R., & Garrison, C. Z. (2001). Prevalence of attention-​deficit/​hyperactivity disorder in a community sample of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1037–​1044. DuPaul, G. J., Power, T. J., Anastopoulos, A. D., & Reid, R. (2016). ADHD Rating Scale-​5 for children and adolescents: Checklists, norms, and clinical interpretation. New York: Guilford. Evans, S. W., Owens, J. S., & Bunford, N. (2014). Evidence-​based psychosocial treatments for children and adolescents with attention-​deficit/​ hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 43, 527–​551. Faraone, S. V., Biederman, J., Keenan, K., & Tsuang, M. T. (1991). A family-​genetic study of girls with DSM-​III attention deficit disorder. American Journal of Psychiatry, 148, 112–​117.

202

 203

Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1993). Prevalence and comorbidity of DSM-​III-​R diagnoses in a birth cohort of 15-​year-​olds. Journal of American Academy of Adolescent Psychiatry, 32, 1127–​1133. Gittelman, R., Mannuzza, S., Shenker, R., & Bonagura, N. (1985). Hyperactive boys almost grown up:  I. Psychiatric status. Archives of General Psychiatry, 42, 937–​947. Goodman, R. (1989). Genetic factors in hyperactivity account for about half of the explainable variance. British Medical Journal, 298, 1407–​1408. Goodman, R., & Stevenson, J. (1989). A twin study of hyperactivity: II. The etiological role of genes, family relationships and perinatal adversity. Journal of Child Psychology and Psychiatry, 30, 691–​709. Hill, J. C., & Schoener, E. P. (1996). Age-​dependent decline of attention deficit hyperactivity disorder. American Journal of Psychiatry, 153(9), 1143–​1146. Hinshaw, S. P., & Arnold, L. E. (2015). ADHD, multimodal treatment, and longitudinal outcome:  Evidence, paradox, and challenge. Wiley Interdisciplinary Review of Cognitive Science, 6(1),  39–​52. Hope, D. A., Heimberg, R. G., & Turk, C. L. (2006). Managing social anxiety: Therapist guide (2nd ed.). New York: Oxford. Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hirpi, E., . . . Walters, E. E. (2005). The World Health Organization adult ADHD self-​report scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35(2), 245–​256. Knouse, L. E., & Mitchell, J. T. (2015). Incautiously optimistic: Positively valenced cognitive avoidance in adults with ADHD. Cognitive and Behavioral Practice, 22(2), 192–​202. Lahey, B. B., Piacentini, J. C., McBurnett, K., Stone, P., Hartdagen, S., & Hynd, G. (1988). Psychopathology in the parents of children with conduct disorder and hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 163–​170. Lerner, M., & Wigal, T. (2008). Long-​term safety of stimulant medications used to treat children with ADHD. Journal of Psychosocial Nursing and Mental Health Services, 46(8),  38–​48. Linehan, M. (1993). Cognitive-​behavioral treatment of borderline personality disorder. New York: Guilford. Maccoby, E. E., & Martin, J. A. (1983). Socialization in the context of the family: Parent-​child interaction. In P. H. Mussen & E. M. Hetherington (Eds.), Handbook of child psychology (Vol. 4). Socialization, personality, and social development (pp. 1–​101). New York: Wiley.

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204

Mattes, J. A., & Gittelman, R. (1983). Growth of hyperactive children on maintenance regimen of methylphenidate. Archives of General Psychiatry, 40, 317–​321. McDermott, S. P. (2000). Cognitive therapy of adults with attention-​ deficit/​ hyperactivity disorder. In T. Brown (Ed.), Attention deficit disorders and comorbidity in children, adolescents, and adults (pp. 569–​ 607). Washington, DC: American Psychiatric Press. Miller, W. R., & Rollnick, S. (2012). Motivational interviewing:  Helping people change. New York: Guilford. Morrison, J. R. (1980). Adult psychiatric disorders in parents of hyperactive children. American Journal of Psychiatry, 137, 825–​837. Morrison, J. R., & Stewart, M. A. (1973). The psychiatric status of the legal families of adopted hyperactive children. Archives of General Psychiatry, 28, 888–​891. Murphy, K. (2005). Psychosocial treatments for ADHD in teens and adults:  A practice-​ friendly review. Journal of Clinical Psychology/​ In Session, 61, 607–​619. Murphy, K., & Barkley, R. A. (1996). Attention deficit hyperactivity disorder adults:  comorbidities and adaptive impairments. Comprehensive Psychiatry, 37(6), 393–​401. Murphy, K. R., & Gordon, M. (1998). Assessment of adults with ADHD. In R. Barkley (Ed.), Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed., pp. 345–​369). New York: Guilford. Naar, S., & Safren, S. A. (2017). Motivational interviewing and CBT: Combining strategies for maximum effectiveness. New York: Guilford. Otto, M. (2000). Stories and metaphors in cognitive-​behavior therapy. Cognitive and Behavioral Practice, 69, 166–​172. Otto, M. W., & Pollack, M. H. (2009). Stopping anxiety medication: Therapist guide (2nd ed.). New York: Oxford. Otto, M. W., Reilly-​Harrington, N. A., Kogan, J. N., Henin, A., Knauz, R. O., & Sachs, G. S. (2009). Managing bipolar disorder: Therapist guide. New York: Oxford University Press. Owens, J. S., Goldfine, M. E., Evangelista, N. M., Hoza, B., & Kaiser, N. M. (2007). A critical review of self-​perceptions and the positive illusory bias in children with ADHD. Clinical Child and Family Psychological Review, 10(4), 335–​351. Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York: Norton. Robin, A. L. (1990). Training families of ADHD adolescents. In R. A. Barkley (Ed.), Attention deficit hyperactive disorder: A handbook for diagnosis and treatment (2nd ed., pp. 462–​497). New York: Guilford.

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Safer, D. (1973). A familial factor in minimal brain dysfunction. Behavior Genetics, 3, 175–​186. Safren, S. A., Otto, M. W., Sprich, S., Perlman, C. L., Wilens, T. E., & Biederman, J. (2005). Cognitive behavioral therapy for ADHD in medication-​ treated adults with continued symptoms. Behaviour Research and Therapy, 43, 831–​842. Safren, S. A., Sprich, S., Chulvick, S., & Otto, M. W. (2004). Psychosocial treatments for adults with attention-​ deficit/​ hyperactivity disorder. Psychiatric Clinics of North America, 27(2), 349–​360. Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M., & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-​treated adults with ADHD and persistent symptoms: A randomized controlled trial. Journal of the American Medical Association, 304(8), 875–​880. Sleator, E. K., von Neumann, A., & Sprague, R. L. (1974). Hyperactive children: A continuous long-​term placebo-​controlled follow-​up. Journal of the American Medical Association, 229(3), 316–​317. Spencer, T., Biederman, J., Wilens, T. E., & Faraone, S. V. (2002). Overview and neurobiology of attention-​deficit/​hyperactivity disorder. Journal of Clinical Psychiatry, 63(supp. 12),  2–​9. Spitzer, R. L., & Williams, J. B. W. (1985). Classification in psychiatry. In H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry (4th ed.). (pp. 591–​613). Baltimore, MD: Williams & Wilkins. Sprich, S., Biederman, J., Crawford, M. H., Mundy, E., & Faraone, S. V. (2000). Adoptive and biological families of children and adolescents with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 11, 1432–​1437. Sprich, S. E., Burbridge, J., Lerner, J. A., & Safren, S. A. (2015). Cognitive-​ behavioral therapy for ADHD in adolescents: Clinical considerations and a case series. Cognitive and Behavioral Practice, 22(2), 116–​126. Sprich, S. E., Safren, S. A., Finkelstein, D., Remmert, J. E., & Hammerness, P. (2016). A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-​treated adolescents. Journal of Child Psychology and Psychiatry, 57(11), 1218–​1226. Stevenson, J., Pennington, B. F., Gilger, J. W. DeFries, J. C., & Gillis, J. J. (1993). Hyperactivity and spelling disability: Testing for shared genetic aetiology. Journal of Child Psychology and Psychiatry, 49, 728–​738. Szatmari, P., Boyle, M., & Offord, D. (1993). Familial aggregation of emotional and behavioral problems of childhood in the general population. American Journal of Psychiatry, 150, 1398–​1403.

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Thiruchelvam, D., Charach, A., & Schachar, R. J. (2001). Moderators and mediators of long-​term adherence to stimulant treatment in children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 40(8), 922–​928. Verhulst, F. C., van der Ende, J., Ferdinand, R. F., & Kasius, M. C. (1997). The prevalence of DSM-​III-​R diagnoses in a national sample of Dutch adolescents. Archives of General Psychiatry, 54, 329–​336. Weiss, M. D. (2000). Weiss Functional Impairment Rating Scale Self-​ Report (WFIRS-​S). Retrieved from https://​www.caddra.ca/​cms4/​pdfs/​ caddraGuidelines2011WFIRS_​S.pdf Wilens, T. E., Adler, L.A., Adams, J. Sgambati, S., Rotrosen, J., Sawtelle, R., . . . Fusillo, S. (2008). Misuse and diversion of stimulants prescribed for ADHD: A systematic review of the literature. Journal of the American Academy of Child and Adolescent Psychiatry, 47(1),  21–​31. Wilens, T. E., McBurnett, K., Bukstein, O., McGough, J., Greenhill, L., Lerner, M., . . . Lynch, J. M. (2006). Multisite controlled study of OROS methylphenidate in the treatment of adolescents with attention-​deficit/​ hyperactivity disorder. Archives of Pediatrics & Adolescent Medicine, 160(1),  82–​90. Wilens, T. E., McDermott, S. P., Biederman, J., Abrantes, A., Hahesy, A., & Spencer, T. J. (1999). Cognitive therapy in the treatment of adults with ADHD: A systematic chart review of 26 cases. Journal of Cognitive Psychotherapy: An International Quarterly, 13, 215–​227. Winterstein, A. G., Gerhard, T., Shuster, J., Zito, J., Johnson, M., Liu, H., & Saidi, A. (2008). Utilization of pharmacologic treatment in youths with attention deficit/​ hyperactivity disorder in Medicaid database. Annals of Psychopharmacology, 42(1),  24–​31. Zametkin, A. J., & Liotta, W. (1998). The neurobiology of attention-​deficit/​ hyperactivity disorder. Journal of Clinical Psychiatry, 59(supp. 7),  17–​23. Zinbarg, R. E., Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry: Therapist guide (2nd ed.). New York: Oxford.

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About the Authors

Susan E. Sprich received her BA in Psychology from the University of Pennsylvania and her PhD in Clinical Psychology from The University at Albany, State University of New York. She completed her clinical psychology internship training and postdoctoral training at Massachusetts General Hospital/Harvard Medical School, and has been affiliated with Massachusetts General Hospital (MGH) since 1994. She has served as the Director of the Cognitive-Behavioral Therapy Program at MGH since 2014. She was appointed as the Director of Postgraduate Psychology Education for the MGH Psychiatry Academy in 2015. She is an Assistant Professor in Psychology at Harvard Medical School. Dr. Sprich is a co-author of 27 chapters and articles on a range of topics including psychosocial treatments for ADHD in adults and adolescents, trichotillomania, and social anxiety. She is the co-author of Mastering Your Adult ADHD—Therapist Guide and Client Workbook, published by Oxford University Press in the Treatments ThatWork series. She served as a co-editor of the MGH CBT Handbook, published by Springer. She teaches and supervises psychology interns and psychiatry residents at Massachusetts General Hospital. She is the Assistant Director of the Psychology Internship Program at MGH. She was the recipient of the Emerson Award from MGH for her dissertation research and was awarded a Scholars in Medicine Fellowship through Harvard Medical School. She was given an award for excellence in mentoring by the psychology interns in 2015 and the Behavioral Medicine Service award in 2018. Dr. Sprich has been involved in research projects focused on ADHD, BDD, OCD, and Autism Spectrum Disorders. Dr. Sprich has extensive clinical experience working with ADHD, anxiety, Trichotillomania, OCD, and other Obsessive-Compulsive Spectrum Disorders. Steven A. Safren received his BA from Brandeis University and his PhD from The University at Albany, State University of New York. He completed his clinical psychology internship and postdoctoral fellowship

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at Harvard Medical School/Massachusetts General Hospital (MGH), where he worked until 2015. He is currently a Professor and Cooper Fellow in the Department of Psychology at the University of Miami. He is also the founding Director of the UM Center for HIV and Research in Mental Health (NIMH-funded Developmental AIDS Research Center D-ARC) and the Health Promotion and Care research program (https://hpac.psy.miami.edu/). Before he moved to Miami, he served in various roles in the Harvard Medical School system and MGH: he was a Professor at Harvard Medical School and Director of the Behavioral Medicine Service at MGH, and led behavioral science studies at Fenway Health. He has been PI or protocol chair of 16 federally funded studies (via NIMH, NIDA, and NIAID) across two different clinical research areas: adult/adolescent ADHD, and health behavior change (HIV prevention and treatment). He has served as Editor of the journal Cognitive and Behavioral Practice and is currently an Associate Editor of Journal of Consulting and Clinical Psychology, and has published over 300 peerreviewed scientific publications in his areas of research.

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