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Introduction

Mother: "Johnny, please get up. It’s time for school. If you don’t start now, you won’t have time for a nice, hot breakfast; and I won’t be able to drive you to the bus."

Johnny: "No. Go away. Leave me alone!"

Poor way to respond, isn’t it? Day after day, it’s hard to fathom how Johnny could choose this ineffective response. But that is just the point. Johnny isn’t choosing anything. In fact, he isn’t even thinking. He’s just reacting. This is because people with ADHD do not inhibit their reactions long enough to talk themselves through the problem.

Typically, people with ADHD have difficulty with "self-talk," i.e., using words to think through a situation. In addition, they make poor choices because they have trouble inhibiting their behavior. If given the correct words with which to calmly consider the problem, they typically know the correct answer. As Russell Barkley points out, ADHD children have a deficiency doing what they know, not in knowing what to do. (See the concept of executive dysfunction in ADHD.)

If people actually stopped to listen to themselves working through the above situation, this is what they would hear:

• What’s the problem?

I have to get up even though I don’t want to.

• What are my possible solutions?

I could rant and rave, scream miserably, get punished, loose all of my privileges, and end up going to school anyway--like always.

I could get up, have a reasonably pleasant breakfast, be praised for being so helpful, and go to school.

• What choice will I make?

Well, when you put it that way, it is not really that tough a choice, is it? I end up going to school either way. But, the first way I get punished; and the second way, I get rewarded. How stupid do you think I am? Of course, it makes sense to just get up calmly.

• How did I do?

Pretty well, don’t you think? Why didn’t I ever think of it this way before? I guess because I never actually thought about it before, at least not with words.

 

What we all need to do when faced with a problem (but ADHD children never learned to do automatically) is to use our brain’s computer to analyze the problem and choose the most effective response. Sometimes, the most productive response is not the most emotionally enticing. In these cases, we depend on the thinking part of our brain to exercise "cognitive override." As helpers to people with ADHD, then, we must help their cognitive abilities override their impulsive emotions--by utilizing the skill of self-talk. This process is called "Cognitive Behavioral Therapy."

General Concepts of Cognitive Behavioral Therapy

• The following technique is adapted from Philip C. Kendall and Lauren Braswell’s book Cognitive Behavioral Therapy for Impulsive Children by Guilford Press.
• "Cognitive" refers to using the thinking—and particularly verbal—parts of our brain to control our actions. Speech is the tool by which humans formulate and manipulate complex ideas.
• "Behavioral" refers to the use of rewards to encouraging use of the technique.
• These skills require practice when the child is calm. Don’t try them initially during stressful times. This is one of the times when you must "strike while the iron is cold."
• These techniques are best taught by a professional therapist.
• We should model the process frequently. We need to demonstrate flexibility, and we need to demonstrate it verbally.
• Time moves very slowly for children with ADHD. At first, the process will seem unnecessary and interminable to them. Be patient.
• This will not work overnight. We are talking about years, if not a lifetime, for ADHD people to master these skills. But what other choice do we have?
• Many ADHD children will not be ready to fully employ these techniques until they have become sufficiently miserable with what they have done to their lives. Hopefully, we can pre-empt that time; or, at least, have the person prepared with the skills for when he is finally motivated to use them.
• Parents and teachers could use a little cognitive therapy on themselves, as well. When we wake our child up in the morning, what is our goal? Is it to facilitate a pleasant experience for everyone and have our child like being around us, or is it to prove that we can force him to make his bed?
• NEGOTIATION will be a large part of the successful answers. We are seeking to teach our children how to achieve win-win solutions. Sometimes these solutions will be less then we would ideally like. More likely, they will be just fine compromises, as long as we can get over any negative connotation to the word "compromise." Don’t worry. You are still in control. You still get to choose when to compromise (virtually always except for safety issues) and what the final terms of the compromise will be. The process certainly beats the alternative: enduring meltdowns or the whittling down of our relationships with our child.
• The following 5 steps need to be explained to the child, and then the child should put each step into his/her own words.

Five Steps of Cognitive Behavioral Therapy

(1) Stop!

• This step is initially the hardest.
• We can’t exercise our powers of self-talk and reason while our brain is being overwhelmed by emotion. This applies to people with or without ADHD.
• Ideally, both the parent and child learn to sense impending emotional overload before it happens.
• The best way to treat a meltdown is to prevent it. Learn the warning signs. Often, they are not very subtle. For example, the child might scream. "Stop, I can’t take it anymore."
• Often, just the act of saying "Stop," and taking a deep breath will be enough of a break.
• Other times, a formal disengagement will be required. Agree, in advance, to a system whereby the child can have a safe, non-punitive place to calm down when needed. The calming down activity should basically be whatever the child wants. Remember, pulling back from the brink is difficult. We are trying to increase the chances that the child will comply.
• Once a meltdown occurs, it typically must run its course before rational discussion can be expected.
• Once a state of calm is present, we can proceed to the actual process.

(2) What is the problem?

• Formulate, in words, "what is the problem we are trying to solve?" What are the goals?
• In order to better understand the problem, "seek first to understand." Where is the other person coming from? What are his/her needs? Why would they possibly be acting this way?
• As a practical step, start formulating the problem by re-stating out loud what the other person just said. This step will force us to listen to what has just been said to us, and will reassure the speaker that we are indeed listening to them.
• Without the language of self-talk, many ADHDers find themselves overwhelmed without coherent thoughts. How do we know when that is happening? Simple. The child starts screaming.
• Examples of forumulating the problem:

• "The problem is that I have to get up but I don’t want to."
• "The problem is that I don’t want to stop playing the computer in order to come to dinner."
• "The problem is that my parents won’t let me go out with my friends."

(3) What are my possible choices?

• The child formulates, in words, all of the different possible solutions or choices that could be made in response to the problem.
• Praise any response at this stage. Admittedly, many of the choices will sound rather stupid when stated out loud. That is the idea.
• Initially, you will have to help the child come up with some of the possible answers.
• Remember, we are seeking win-win solutions.
• Examples:

• "I could scream that I am never coming for dinner."
• "I could totally ignore the request."
• "I could go have an enjoyable meal with my family. After all, mommy made me something that I like, she did all of the work, and all I have to do is come eat it. And I do have to eventually eat."
• "I could negotiate. I’ll propose that I will come up in 4 minutes. I’ll set a timer so that my parents will be more likely to accept my proposal."

(4) "What is my choice?"

• From the possible choices in the previous step, select the best one—using words! A good choice should meet the following criteria:

• Which choice will achieve a win-win situation?
• Which choice is likely to be accepted by all parties?
• Which choice is likely to work?

• Usually, ADHD children will make a pretty good choice if they have made it this far. Sometimes, they will need a little guidance. In particular, their planning for the future and their sense of timing may need some help.
• Children with Asperger’s Syndrome will tend to need more instruction on the actual correct answer to a social situation. Often, they can be "scripted" with an appropriate response.
• Example:

• "Ignoring the request to come for dinner is unlikely to work. Mommy will eventually keep pestering me, and eventually I’ll become hungry, anyway. I can’t come right now because I’ll loose my spot in the game if I exit at this point. Negotiate! Mommy always goes for that. Better that I come peacefully in 4 minutes than screaming which will ruin all of dinner. I’ll propose coming in 4 minutes. But I better keep to the plan if I expect mommy to accept it next time."

(5) How Did I Do?

• How good was my effort in the problem solving process?

• Did I really try?
• Did I stick to the steps?
• Did I use words?

• How good was my result?

• Did I achieve a win-win situation?
• Did the solution actually work?

(6) Reward!!!

• This step is always positive.
• Rewards can be internal: Hopefully, the child can say to himself: "Great job!! It worked!!" Sometimes, he’ll have to settle for "Nice try. Better luck next time."
• Rewards can be external: Praise whatever positive thing you can find about the process or its effort.
• Remember that we are trying to increase compliance with the process by making it more useful and pleasant. Punishment has no role here. That will only lead to avoiding the system altogether. However, good results with the system can be specifically rewarded with privileges.

 

Summary

Here are the steps of cognitive behavioral therapy for impulsivity:

1. Stop.
2. What is the problem?
3. What are the possible choices?
4. What is my choice?
5. How did I do?
6. Reward.

Good luck!

--Martin L. Kutscher, MD  © 2002

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