ADHD is not a pathology to be cured. It is a difference to be explored and respected. This truth is self-evident but begs the question: How do we help people manage their ADHD without erasing the traits that shape who they are?

Increasingly, cognitive behavioral therapy (CBT) is being used to support executive functions and reshape environments to encourage behavioral change. At the same time, it works to reduce the shame, avoidance, and perfectionism that so often accompany ADHD.

Unlike other therapies, CBT measures patients’ outcomes in relation to their goals rather than ADHD symptom reduction. It supports patients’ time management, organization, emotional regulation, and other skills – not by encouraging them to change who they are, but by providing tools to improve functioning in ways that are meaningful to them.

CBT is most effective when it is designed collaboratively and personalized to meet a patient’s needs. For therapists, these guidelines for delivering neurodiversity-affirming care are a good place to start:

CBT Techniques for ADHD: Guidance for Therapists

💡Free Guide! 10 Things I Wish Someone Had Told Me About ADHD

1. Normalize ADHD

To aid patients in breaking unhelpful patterns, you must first understand and explain how ADHD impacts thoughts, behaviors, and emotions, Make the connection clear from a framework of difference, not deficits. Here’s an example:

PATIENT: I should be starting my report, but I keep thinking, I can’t do this. I’m a failure. I get anxious, scroll through my phone, and feel worse.

PRACTITIONER: That loop makes sense. With ADHD, large tasks demand a lot of executive functioning. When the first step isn’t clear, the brain sends an “avoid” signal. With that said, what’s a more balanced thought that still feels honest?

PATIENT: Starting is hard when the task is vague, but I’ve handed in reports before. I can begin if I make the first step tiny.

2. Follow the Patient’s Lead

When a patient tries to broadly suppress their ADHD symptoms, they end up consciously or unconsciously masking their identity. While most people mask to some degree, constant camouflaging leads to lower life satisfaction.

Abandon preconceived notions about impairing symptoms or challenges. Instead, ask your patient about their goals and the behaviors they want to change. Say:

• What would you prefer to focus on – career, health, relationships, or something else?
• What are your goals in this area?
• What tasks put you in line with your goals?

💡Read: What Makes a Life Fulfilling? Pursuing Goals Important to You, Not Others.

3. Watch Your Language

Does your patient prefer identity-first language (“ADHD person”) or person-first language (“person with ADHD”)? Do they have a preferred term for their neurotype? For example, Variable Attention Stimulus Trait (VAST), coined by Edward Hallowell, M.D., and John Ratey, M.D., is an alternative term for ADHD that has grown in popularity. Use non-pathologizing terms (also based on patient preference):

4. Look Beyond the Individual

Is your approach centered on making individuals meet neurotypical standards? Are you exploring opportunities to reshape their environment to help them thrive? For instance, you might suggest that a patient relocate to a quieter corner of their office and schedule brief, daily check-ins with their supervisor.

5. Provide Supports

The skill-building and between-session tasks associated with CBT can be difficult for people with ADHD, possibly triggering rejection sensitivity. To address this barrier to care:

• Supply tools. Provide a timer, for example, rather than asking your patient to buy one.
• Gauge what can be done. Ask, “On a 10-point scale, with 10 being a done deal, how likely are you write in your thought journal every day?” If their answer is less than eight, adjust the task.
• Plan frequent check-ins for accountability and opportunities to troubleshoot.
• Suggest options. A paper checklist may help one patient stay organized, while a to-do list app may work better for another. Always give choices and allow patients to experiment autonomously.

Saskia Van Der Oord, Ph.D., is a professor of clinical psychology at KU Leuven in Belgium.

Michael Meinzer, Ph.D., is an associate professor of psychology at the University of Illinois, Chicago.

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When I began my academic career 40 years ago, ADHD or “hyperactivity” was considered a school disorder in children. The treatment was twice-daily immediate-release methylphenidate, designed to help children focus from 8 a.m. to 3 p.m., give or take.

Today, we know that ADHD affects every life domain and that medication alone is usually not sufficient. Most people need multimodal care, and the sequence of treatments matters; however, few patients benefit from these insights because ADHD care is fragmented in the following ways:

• Its quality hinges on who diagnoses the ADHD, when, and which services are available and utilized.
• How and when care is delivered.
• Untreated or undertreated ADHD is far too common.

Providing a Structured Approach

There is no one-size-fits-all approach to ADHD. An effective ADHD treatment plan for children begins with a comprehensive assessment that considers the following:

Co-occurring Conditions and Mimics

ADHD coexists with at least one psychiatric, learning, or behavioral disorder about 80% of the time. Anxiety, depression, sleep disturbance, and other conditions can imitate or amplify symptoms.

Unique Impairments

Treatment should be tailored to each child’s unique impairment and context (e.g., severity, presentation, family dynamics, parental health, care access, etc.) while simultaneously highlighting the child’s strengths. Identifying and building on a child’s talents promotes self-esteem and resilience.

💡Free Guide! Parent-Child Therapies for Better Behavior

Sleep Comes First

Sleep problems and ADHD often overlap and are mutually exacerbating; stimulants can disrupt sleep, and poor sleep can worsen ADHD symptoms. Baseline sleep history and screening for sleep disorders should precede medication trials. If sleep deteriorates, clinicians should adjust the dose or formulation, add melatonin, or reinforce sleep-hygiene routines.

Multifaceted Treatment Is Best

Research has focused extensively on monotherapy — typically medication alone — but this approach rarely suffices beyond the short term. For one, ADHD can change over time. The medication that helps a hyperactive kindergartener may not serve a high school student. Monotherapy is especially inadequate for patients with multiple symptoms, comorbidities, and residual impairments not addressed by medication, like behavioral challenges when a medication wears off.
Multimodal therapy — medication used in conjunction with new behavioral interventions — is not new. The landmark Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study observed children assigned to different 14-month approaches:

• individually titrated medication
• intensive behavioral intervention
• combined treatment
• community care

Medications improved core symptoms, but parents and teachers rated the combined approach highest for overall functioning.

💡Free Download! A Parent’s Guide to ADHD Medication

Sequence Matters

Multimodal treatment works, but sequencing is important. In one study, children were treated during a school year and assigned to different sequences. Starting with behavioral treatment and then adding medication, if needed, produced the best outcomes, including fewer classroom rule violations and disciplinary events. Conversely, starting with medication and adding behavioral treatment later was less effective. ¹

Dosing for Non-Stimulants

For patients who do not respond to stimulants, choose not to take them, or whose comorbid conditions (e.g., tics, sleep disorders) are worsened by stimulants, non-stimulants are an option, and there are several with different mechanisms of action. Finding an optimal dose requires working closely with your provider. Often, combining stimulants with non-stimulants can improve tolerability and mitigate dose-related side effects.

What constitutes effective ADHD treatment will continue to be a central topic of research. Scientific evidence supports care that is personalized, sequenced, and measurement-based. Children respond best to treatment plans that include psychoeducation, behavioral and pharmacological interventions, and a focus on building their strengths to improve functioning not just in school but in life.

Mark A. Stein, Ph.D., is a professor of psychiatry and behavioral sciences at the University of Washington.

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Source

^{1 Pelham, W.E., Jr., Fabiano, G.A., Waxmonsky, J.G., Greiner, A.R., Gnagy, E.M., et al. (2016). Treatment sequencing for childhood ADHD: a multiple-randomization study of adaptive medication and behavioral interventions. J Clin Child Adolesc Psychol. https://doi.org/ 10.1080/15374416.2015.1105138}