COGNITIVE-BEHAVIOURAL THERAPY FOR ADHD IN ADOLESCENTS AND ADULTS YYoouunngg__ffffiirrss..iinndddd ii 22//2244//22001122 1111::3333::3355 AAMM COGNITIVE-BEHAVIOURAL THERAPY FOR ADHD IN ADOLESCENTS AND ADULTS A PSYCHOLOGICAL GUIDE TO PRACTICE SECOND EDITION Susan Young and Jessica Bramham A John Wiley & Sons, Ltd., Publication YYoouunngg__ffffiirrss..iinndddd iiiiii 22//2244//22001122 1111::3333::3355 AAMM This edition first published 2012 © 2012 John Wiley & Sons, Ltd. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered Office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 350 Main Street, Malden, MA 02148-5020, USA 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell. The right of Susan Young and Jessica Bramham to be identified as the authors of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. 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, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. 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Library of Congress Cataloging-in-Publication Data Young, Susan, 1957– Cognitive-behavioural therapy for ADHD in adolescents and adults : a psychological guide to practice / Susan Young and Jessica Bramham. – 2nd ed. p. cm. Rev. ed. of: ADHD in adults / Susan Young, Jessica Bramham. 2007. Includes bibliographical references and index. ISBN 978-1-119-96074-4 (hardback) – ISBN 978-1-119-96073-7 (paper) 1. Attention-deficit disorder in adults–Treatment. 2. Attention-deficit disorder in adolescence– Treatment. 3. Cognitive therapy. I. Bramham, Jessica. II. Young, Susan, 1957– ADHD in adults. III. Title. RC394.A85Y68 2012 616.85′89–dc23 2011053429 A catalogue record for this book is available from the British Library. Set in 10/12pt Times by SPi Publisher Services, Pondicherry, India 1 2012 YYoouunngg__ffffiirrss..iinndddd iivv 22//2244//22001122 1111::3333::3366 AAMM CONTENTS List of Figures, Tables and Boxes vii About the Authors x Foreword by Margaret Weiss xi Foreword by Sam Goldstein xviii Preface xxi Acknowledgements xxiii I BACKGROUND AND TREATMENT 1 1 Introduction 3 2 Delivering the Young-Bramham Programme 21 II CORE SYMPTOM MODULES 37 3 Attention Module 39 4 Memory Module 54 5 Organization and Time-Management Module 64 6 Impulsivity Module 91 III COMORBID AND ASSOCIATED PROBLEM MODULES 109 7 Problem-Solving Module 111 8 Interpersonal Relationships Module 129 9 Anxiety Module 153 10 Frustration and Anger Module 182 YYoouunngg__ffttoocc..iinndddd vv 22//2222//22001122 1111::3311::5544 PPMM vi CONTENTS 11 Low-Mood and Depression Module 203 12 Sleep Module 221 13 Substance Misuse Module 243 IV THE FUTURE MODULE 267 14 Preparing for the Future Module 269 References 285 Index 294 YYoouunngg__ffttoocc..iinndddd vvii 22//2222//22001122 1111::3311::5544 PPMM LIST OF FIGURES, TABLES AND BOXES Figures 1.1 A cognitive behavioural model of ADHD in adults 12 2.1 Stages of change 28 3.1 The spiral of anxiety and attentional control 46 4.1 Memory systems 55 4.2 Working memory model 56 5.1 Example of breaking down goals into steps 74 5.2 Prioritization methods 76 7.1 Example of brainstorming solutions 119 8.1 How to communicate effectively 138 9.1 Anxiety spiral 160 9.2 Thought bubble anxiety spiral 162 9.3 The three-legged anxiety table 162 9.4 The three-legged anxiety table: Coping with negative thoughts 165 9.5 Bodily reactions to anxiety 171 9.6 The three-legged table: Controlling feelings of anxiety 173 9.7 The three-legged table: Changing behaviour 176 10.1 Physical, cognitive and behavioural aspects of anger 191 10.2 Dealing with insults and criticisms 199 11.1 Cognitive model of depression in ADHD 207 12.1 Dysfunctional sleep cycle 223 12.2 The sleep cycle 232 13.1 Context of substance misuse for people with ADHD 244 13.2 The sequence of thoughts and beliefs during cravings and urges 261 13.3 Dysfunctional beliefs that can maintain substance misuse 262 14.1 Steps towards goals 275 Tables 3.1 DSM-IV checklist of symptoms 42 3.2 Examples of attentional impairments 44 3.3 External strategies to improve attentional control 48 3.4 Internal strategies to improve attentional control 49 4.1 Memory problems log 59 4.2 External strategies to improve memory 60 YYoouunngg__ffbbeettww..iinndddd vviiii 22//2233//22001122 33::2255::5522 PPMM viii LIST OF FIGURES, TABLES AND BOXES 4.3 Internal strategies to improve memory 61 5.1 Time-management evaluation 67 5.2 Importance of punctuality evaluation 68 5.3 Diary activity log 69 5.4 Time-estimation exercise 79 5.5 Time plan 81 5.6 Example of diary activity plan 83 6.1 Typical impulse control problems experienced by people with ADHD 93 6.2 The IMPULSE method for identifying and monitoring behaviours 98 6.3 The process of CONTROL 102 6.4 Distraction techniques 104 7.1 Common domains of problems in ADHD 117 7.2 Understanding the problem 118 7.3 Example of a pros and cons list 122 8.1 Social skills questionnaire 132 8.2 Characteristics of ADHD speech and suggestions for improvement 134 8.3 Conversational skills 134 8.4 Listening skills 135 8.5 Emotions and facial expressions 137 9.1 Anxiety checklist 157 9.2 Example of a thought diary 163 9.3 Example of negative challenges in a thought diary 164 9.4 Cognitive techniques and the process of anxiety 165 9.5 Thinking errors 167 9.6 Examples of negative thoughts and challenges 168 10.1 Measure of assertion 190 11.1 Typical thinking errors of people with ADHD 209 11.2 Examples of negative thoughts and challenges 213 11.3 Diary activity plan 217 12.1 Sleep diary 227 12.2 Stages of sleep 231 12.3 Factors which may affect sleep in people with ADHD 234 12.4 Behavioural sleep strategies 236 13.1 The five stages of substance use 249 13.2 Problems associated with substance misuse 250 13.3 Substance, stage and motivation 251 13.4 Decisional balance sheet 256 13.5 Distraction and replacement techniques 260 13.6 Addictive beliefs 262 14.1 Review of successful strategies 277 YYoouunngg__ffbbeettww..iinndddd vviiiiii 22//2233//22001122 33::2255::5522 PPMM LIST OF FIGURES, TABLES AND BOXES ix Boxes 1.1 The Young-Bramham programme structure 15 5.1 Six steps to making a time plan 73 5.2 List components 75 5.3 Priority task list 77 5.4 Organizing a repeat prescription 78 6.1 ‘Double-check’ questions 103 7.1 Define the Problem 116 9.1 Anxiety chart: What happens to you when you become anxious? 159 9.2 Positive self-statements 169 9.3 Ten rules for coping with panic 172 9.4 Breathing exercises 174 9.5 Progressive muscle relaxation 175 9.6 Overcoming avoidance and increasing confidence 177 9.7 Example of stage 1: List of situations avoided 177 9.8 Example of stage 2: Grading of list of situations avoided (0–10) 178 9.9 Example of stage 3: Ranking list of situations avoided (0–10) and choosing rewards 178 10.1 The ADHD formula 195 11.1 Thinking errors exercise 209 11.2 Brainstorming Techniques 212 11.3 Exercise: Challenging negative thinking 212 11.4 Replacing negative thoughts 213 11.5 Making a task list 214 11.6 Example of a task list for activity scheduling 216 12.1 Examples of the thoughts, feelings and behaviours that mediate sleeplessness 239 12.2 Mood-related sleep strategies 240 13.1 Risk domain exercise 252 13.2 Five stages of seeking help 254 13.3 The problem of change 255 13.4 Weighted advantages/disadvantages worksheet 257 13.5 Distraction techniques 260 13.6 Flashcards of self-reinforcement 263 14.1 Top ten achievements 275 14.2 Future goals 275 YYoouunngg__ffbbeettww..iinndddd iixx 22//2233//22001122 33::2255::5522 PPMM ABOUT THE AUTHORS Susan Young is a Senior Lecturer in Forensic Clinical Psychology at the Institute of Psychiatry, King’s College London and an Honorary Consultant Clinical and Forensic Psychologist at the high security Broadmoor Hospital. In 1994 Susan set up the clinical psychology service at the Maudsley Hospital’s National Adult ADHD Service and has extensive clinical experience in the assessment and psychological treatment of youths and adults with ADHD. Susan participated in the British Association of Psychopharmacology Consensus Meeting (2007) to develop guidelines for management of transition for ADHD adolescents to adult services. She was a member of the National Institute for Health and Clinical Excellence (NICE) ADHD Clinical Guideline Development Group (2009); her main contribution being to provide expert guidance on psychological treatment of children and adults with ADHD. Susan is Vice President of the UK Adult ADHD Network (UKAAN), which aims to support practitioners establish adult ADHD clinical services. Susan has published articles in scientific journals, three psychological intervention programmes and has authored two books. She is currently leading a research group, supported by the Department of Health, which aims to develop projects that will establish the evidence base on ADHD and offenders and approaches to their management in the criminal justice system. Jessica Bramham is a Lecturer in Clinical Neuropsychology in the School of Psychology, University College Dublin. She leads the Adult ADHD Service at St Patrick’s University Hospital Dublin. She previously coordinated the National Adult ADHD Service at the Maudsley Hospital in London and was a Clinical Lecturer at the Institute of Psychiatry, King’s College London. Jessica has a doctorate in Clinical Psychology and PhD from the Institute of Psychiatry and a MA from Cambridge University. Neuropsychological assessment is a particular interest. She is involved in researching cognitive functioning and the presentation of comorbid disorders in adults with ADHD. YYoouunngg__ffbbeettww..iinndddd xx 22//2233//22001122 33::2255::5522 PPMM FOREWORD BY MARGARET WEISS ‘The journey started with the words “You have ADHD”. To the client these words were not just a diagnosis, but a framework for self-understanding.’ These words taken from the authors’ module on terminating therapy are a statement of the central thesis of this book. This is a clinically driven manual for understanding and helping adults with ADHD. The strength of this manual is that it is clinically driven. The authors are not constrained by a particular view of how change occurs, the structures of the DSM or ICD, the ideology of a particular method of therapy, or a narrow arena of functional impairment. Young and Bramham define three ways in which change may occur. Biological change may occur either through maturation or as a result of taking medication, in which case one observes a direct improvement in symptoms. Environmental change can occur when the patient’s milieu is modified in such a way as to minimize the impact of symptoms or optimize the visibility of strengths. Psychological change occurs through the use of cognitive, behavioral, psychoeducational and interpersonal techniques that provide a scaffolding for building skills that were not previously present. The authors further simplify this schema for understanding change by noting that it can occur from the outside in, as well as from the inside out. Psychiatrists who prescribe medication and CBT therapists are most interested in change from the inside out. The focus of these authors is not on any one direction of change. Instead they have focused on the dialectic between symptoms and function- ing that is unique to this particular group of patients. This is a book by clinicians who have learned about ADHD from their patients. The result is a practical manual that can be as easily referenced in individual, group or workshop formats. The instrumen- tal tools that accompany each module are made available to the reader on a website for ease of presentation. What emerges from this perspective is clinical wisdom. One can see and feel both the patient and the therapy. Sometimes the authors sound almost simplistic in stating the obvious ‘Achievement is a strong reinforcer’, ‘Self monitoring can increase a skill’, ‘Recognizing and preparing for problematic tasks makes a difference’. Yet each one of these statements represents tasty therapeutic spice. YYoouunngg__ffbbeettww..iinndddd xxii 22//2233//22001122 33::2255::5522 PPMM