ADHD: Identify and Leverage Mechanisms of Change

The core elements of a behavioral approach to treatment have historically focused on the use of operant and classical conditioning by parents and teachers. Some research exists indicating that much of the impairment associated with ADHD reflects a performance deficit, not a skills acquisition deficit (e.g., Aduen et al., 2018). This finding may explain why psychoeducation approaches are not effective with these children (e.g., traditional social skills training; Evans et al., 2018), but can be effective when taught in the context of an intensive behavioral program that uses operant conditioning principles to address performance deficits (Pelham et al., 2014). In addition, there has been research on malleable characteristics of children with ADHD that may explain the effectiveness of behavior modification approaches, such as reward sensitivity (Tenenbaum et al., 2018; Tripp & Alsop, 2001). Identification and an improved understanding of malleable constructs that are causally related to impairment in children with ADHD will help us improve our behavioral interventions and their long-term benefits.

Cognitive or cognitive behavioral therapy (CBT) has an interesting history for youth with ADHD. The original putative mechanism of change for CBT was that children with ADHD were not adequately thoughtful before acting and by teaching children to think out loud, one could improve their thoughtfulness, planning, and problem-solving prior to exhibiting impulsive behaviors (e.g., Meichenbaum & Goodman, 1971). Although one could teach children with ADHD to do this during sessions, the skill rarely persisted after leaving the clinician. CBT reemerged in the last decade as a potential approach to treating adolescents and adults with ADHD; however, clinical trials of CBT with adolescents with ADHD have not resulted in improvements in functioning (e.g., Boyer et al., 2015; Sprich et al., 2016; Vidal et al., 2015), and the potential mechanism of change specifically related to ADHD has not been clearly elucidated. Further, although negative self-statements are commonly observed in adolescents with ADHD (like James), and cognitions are likely malleable, there is not yet evidence to suggest that they are causally related to the impairment that is specific to ADHD.

In order to develop effective cognitive interventions for youth with ADHD, there is a critical need to improve our understanding of cognitive factors that may be causally related to impairment associated with ADHD and to develop techniques to effectively change those specific factors. It is important to consider the possibility that CBT may not be a fruitful path for adolescents with ADHD. Most disorders that can be treated effectively with CBT (e.g., anxiety, depression) involve individuals who think too much (e.g., ruminating, worry) and their thinking is thought to affect their emotions and behavior (Beck, Rush, Shaw, & Emery, 1979). Conversely, adolescents with ADHD tend to not think enough before acting (i.e., impulsivity) and there are questions about the degree with which their thoughts adequately shape their behavior.