ADHD Therapy Comparison: CBT vs. ADHD Coaching

ADHD Therapy Explained: CBT vs. ADHD Coaching

Roughly one-fifth of all adults with ADHD have tried cognitive behavioral therapy (CBT) and/or ADHD coaching — two popular natural treatments receiving ratings of ‘extremely effective’ or ‘very effective’ by 41% and 48% of ADDitude readers, respectively.¹ Still, some confusion persists.

CBT is a short-term, goal-oriented form of psychotherapy that aims to change negative patterns of thinking and change the way patients feels about themselves, their abilities, and their future. CBT is supported by clinical evidence and research results showing that the therapy delivers real-world benefits for adults with ADHD — namely higher self-esteem, productivity, and happiness.

ADHD coaching is an ongoing collaborative partnership created to facilitate greater self-awareness, self-regulation, and self-initiative for clients with ADHD. It is built upon unconditional acceptance and a powerful appreciation of the client’s potential, uniqueness, strengths, capabilities, and wholeness. ADHD coaches are well-versed in ADHD-specific coaching competencies. The coaching process empowers clients to accomplish personal and professional goals with customized strategies built specifically for ADHD minds.

In the recent ADHD Experts webinar “How CBT and ADHD Coaching Help Adults Manage Their Symptoms Naturally,” Dr. Russell Ramsay and David Giwerc highlighted the differences between CBT and ADHD coaching, and explained how each ADHD therapy helps mitigate symptoms of ADHD. Below, they answer some of the most common questions from ADDitude readers.

1.Where can I find accredited practitioners of both CBT and ADHD coaching?

ADHD Coaching

The Professional Association of ADHD Coaches (PAAC), ADD Coach Academy, ADDCA, ADHD Coaches Organization (ACO) are all helpful websites.

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CBT

The following are recommended resources for finding experienced CBT practitioners:

• Adult ADHD Program, Penn Psychiatry
• Duke ADHD Clinic
• Resources section of Intensive CBT: How Fast can I Get Better?
• The referral list for the American Professional Society of Attention and Related Disorders (APSARD)
• Harvard, Duke, University of North Carolina, UCLA, USC, and Penn State have adult ADHD programs and that may offer referrals
• Try reaching out to authors of books on adult ADHD who might have referrals

2. Aside from checking accreditation, what should patients with ADHD look for and ask when assessing whether an ADHD coach or CBT practitioner is a good fit for them?

ADHD Coaching

The relationship between coach and client is a partnership; a good fit is vital. This article presents a list of questions to ask a prospective ADHD coach. In the responses, listen for less tangible, but equally important characteristics such as style, energy, and tone from each prospective coach. This guide from the ADDCA Blog can help provide additional guidance.

CBT

I’d recommend asking about their experience working with adults with ADHD, including diagnostic evaluations and follow-up therapy. Ask about the CBT manuals or other books with which they are familiar, and their view on the executive function model of ADHD. This will also be a way to get a sense of “fit,” though that can be a different matter.

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3. ADHD coaching services are often available via Zoom or other video platforms. Is the same true for CBT? Do practitioners typically accept and begin treating new patients digitally?

It depends on the state, but most are allowing cross-state services by licensed psychologists, or have made it easy to obtain a temporary license. This will likely persist after restrictions due to COVID, at least within states. There is a consortium of states through PsyPACT that will credential therapists to provide remote services across state lines for those participating states.

4. How young can an individual begin and benefit from ADHD coaching and/or CBT? Are these treatments appropriate for teens? Is it possible to be too old to benefit from ADHD coaching and/or CBT?

ADHD Coaching

Coaching is appropriate for children, adolescents, young adults, and adults. Chorological age is not a criterion for coaching; it is the age level of the individual’s neurological functioning that is important. An 18-year-old may have the executive functions of a 13-year-old. A well-trained ADHD coach will support a client based on the age level of executive functioning exhibited during coaching.

Teen coaching, for example, requires customized education that is incorporated into the session in an engaging way. A teen may need to focus on a specific task, sustain their focus, and associate it with something that helps them understand it. For the teen to make progress, parents need to be educated about their child’s type of ADHD and their child’s weaknesses and strengths.

ADD Coach Academy has an accredited family training program dedicated to teaching ADHD coaches the dynamics of the family and how to best work with children of different ages who have ADHD. Coaches are only eligible for family training after they have completed the key requirements for ADHD basic coach training or ADHD advanced coach training.

ADHD coaching can also be very effective for older individuals, who are wiser in terms of experience and context. One difference may be that an older person with ADHD may need more time to access information from their long-term and working memory. A good ADHD coach would bear this in mind and provide more space and time for the older client to process and articulate their responses when questioned.

CBT

Though CBT is largely used with adults, there are some initial studies of the adult ADHD CBT approaches being “down-fitted” for older teens with ADHD. There are some CBT approaches specific to school and driving designed specifically for teens. High school-age teens with ADHD could benefit from CBT, though their receptiveness will likely be an issue.

One does not age out of CBT for adult ADHD. In fact, seniors with ADHD are a growing group, though no specialized protocols exists yet. Kathleen Nadeau, Ph.D., is currently working on a book on seniors with ADHD – her content on ADDitude might provide additional information.

5. What would you recommend for children with ADHD who struggle with executive functions, negative thinking patterns, etc.?

ADD Coaching

Working with children and their families may be the biggest segment of ADHD coaching with the largest demand. In fact, ADDCA created a specialty family training program that focuses on the dynamics of the family.

So long as children are able to communicate and be engaged in a structured but flexible coaching conversation, coaches with family training work with young children adolescents, teens college aged and young adults.

CBT

For elementary school children, parent and teacher training are still the preferred approaches. There are some CBT approaches modified for children to help with thought patterns and behaviors — for example, the past work of Phil Kendall. Richard Gallagher, Howard Abikoff, and colleagues also have a wonderful program for building organizational skills in children. The Smart But Scattered (#CommissionsEarned) series also offers a wonderful approach for executive functions, not limited to ADHD.

6. Does ADHD coaching exist for parents to teach them ways to better communicate with and guide their young children with ADHD? (Or is behavioral parent training the more appropriate choice here?)

An ADHD coach will work with parents to identify ways to communicate with their children that encourages growth, curiosity, and confidence. ADHD coaches help parents become aware of what will positively activate their child’s brain and reinforce what they can do using their strengths. The parents also must be aware of the natural sources of motivation for their child.

7. Is it necessary to have a formal ADHD diagnosis before pursuing coaching and/or CBT?

ADHD Coaching

Yes, a formal assessment or evaluation with a health care practitioner who specializes in the diagnosis and treatment of ADHD and co-occurring conditions is a vital component of effective comprehensive treatment of ADHD.

ADHD coaching is an integral component of comprehensive treatment. However, ADHD coaches are not diagnosticians. Coaching can bridge the gap between biology and behavior, but it is not the only answer. Effective treatment often includes an ADHD psychiatrist, a CBT therapist who is experienced with ADHD, and a well-trained ADHD coach.

When a coaching client is frustrated by their ability to function in specific situations, tasks, and environments, then I refer them to an MD specializing in the diagnosis and treatment of ADHD or a therapist who is experienced with the diagnostic process for ADHD and co-occurring conditions. The doctor can help the patient receive a proper diagnosis, which unlocks targeted medication at a correct dosage. Research tells us that, in 80 percent of cases of ADHD, treatment with stimulants will mitigate the impairing symptoms of ADHD. Even then, the pill does not give you the skill. But it may put a client on a level playing field to pay attention and sustain focus so they can work with a coach.

CBT

CBT focuses on problems and solutions, so even if someone does not meet diagnostic criteria for ADHD but struggles with executive functions (EF), they could likely benefit from the CBT approach for ADHD. That said, some sort of initial interview is good practice in order to determine what is causing the EF difficulties, such as an adjustment to school/work, or mood or anxiety issues, as some modification of treatment might be indicated.

8. With a diagnosis, do some insurance plans cover the cost of CBT and/or coaching for ADHD symptoms?

Most insurance plans do not cover ADHD coaching. Clients pay out of pocket. In rare cases where they do pay, Insurance companies will limit the number of sessions. This does not allow for adequate sessions to support clients. Plus, it disrupts the client’s momentum especially when they are experiencing success. ADHD coaching requires more time than life coaching to get through the invisible barriers impeding the client’s ability to create progress in different areas of their life.

9. Can you offer some guidance re: reasonable costs for CBT and ADHD coaching services? (Cost appears to be a formidable and common barrier to treatment for many people in attendance today.)

ADHD Coaching

As a general guide, ADHD coaching costs about the same as therapy or life coaching. One-hour sessions may range in price from $75 to $250, and sometimes more. There are many variables that impact the costs of coaching. The question that needs to be asked is this: How much is coaching improving the quality of my life or my child’s worth? If coaching can dramatically improve satisfaction, fulfillment, contribution, and productivity in the world, what would I be willing to pay? Costs must be addressed with each coach being considered because the cost of ADHD coaching varies.

• There are ways to reduce the costs for ADHD coaching services. A growing number of coaches are offering a sliding-scale fee based on your level of financial comfort or a percentage of your annual income. When interviewing, ask the coach about possible alternatives to their full fee. Sometimes, if the coach and potential client have a strong connection, they might be willing to work with you.
• If you are seeking coaching in the workplace to improve your performance or prepare for a new role, you can approach your Human Resources department and request reimbursement for the full fee or a portion of the fee. However, by doing this you are informing your company about your ADHD diagnosis. Many adults choose not to do this due to negative perceptions associated with the disorder.

CBT

Pricing for CBT depends on where one lives, private practice vs. clinic-based therapists, etc. The Penn Psychiatry Adult ADHD Program has reduced fees for trainee clinicians. Clinical psychology graduate programs often offer reduced fees for supervised graduate therapists, though it depends on the program for CBT and/or ADHD services.

10. What are some reasonable metrics for success? How can we tell if the coaching or CBT is working the way it should?

ADHD Coaching

The ADD Coach Academy participated in a study assessing the benefits of ADHD coaching for college students. The metrics of success we looked at were improvements on measures of self-efficacy, knowledge of personal learning style, and measures of self-control. Reduced procrastination, consistent completion of goals, and increased confidence in strengths were some of the observable outcomes.

CBT

What are your behavioral goals for CBT and are you meeting those goals for change? Follow-up scores on symptom and EF measures gathered during the initial evaluation can also be reviewed to assess change. Also, ask someone who lives with the patient if he or she notices a difference.

11. Can you explain the differences between CBT and DBT?

Both fall under the CBT umbrella. DBT emerged as the treatment of choice for Borderline Personality Disorder and focuses on emotional regulation and tolerating and managing emotional dysregulation, often accompanied by self-harming and suicidal behaviors. DBT comprises different coping modules that also address setting limits, asking for help, and modifying interpretations (thoughts) about feelings. DBT has been modified for adult ADHD by Alexandra Philipsen in Germany, developing coping modules geared for adult ADHD rather than the main focus on emotional dysregulation.

Acceptance and Commitment Therapy or ACT is another such “third wave” of behavioral therapies that emphasizes the ability to accept and tolerate emotional discomfort and negative thoughts without necessarily changing them as a precondition for engaging in (committing to) valued actions.

12. How long has CBT been used to treat ADHD? How ‘new’ is it, really?

The first outcome study (a chart review) of CBT for adult ADHD was published in 1999 by a Harvard group. Our program started in 1999, so it has been little over 20 years that it has been used in practice, but the past decade has seen a geometric progression of outcome studies in support of its use.

<13. Is CBT also helpful for patients who have autism spectrum disorder and ADHD? Autism on its own? What about bipolar disorder?

That has not been studied. It would seem that the EFs are a point of overlap, though the ASD features are different. Valerie Gaus had published on CBT for Aspergers Syndrome, which is relevant. CBT is an effective psychosocial treatment for Bipolar Disorder, but often requires concurrent medication management, not unlike cases of ADHD. There have been no studies of CBT for adult ADHD plus Bipolar Disorder.

14. Can CBT and/or coaching help an individual who suffers from the rejection sensitive dysphoria so common in adults with ADHD, especially women?

ADHD Coaching

ADHD coaching can help someone who struggles with rejection sensitive dysphoria.

RSD is extreme emotional hypersensitivity and pain triggered by the perception that a person has been rejected or criticized by important people in their life. It may also be triggered by a sense of failing to meet their own high standards or others’ expectations.

When an individual with ADHD comes to coaching without understanding their dominant “rejection/failure story,” they have created a mindset already predisposed to feeling rejected or unable to meet the unrealistic expectations forged in their brain.

People who struggle with both ADHD and RSD are generally not aware of the mechanisms that can trigger RSD and how it immobilizes their ability to function. A common focus of coaching would be a collaborative partnership of coach and client dedicated to improving the client’s self-awareness about specific situations, people, thoughts, and language that often trigger the negative emotions that spiral into ruminative episodes of RSD.

A good ADHD coach will listen to their client’s thoughts, feelings, and patterns — and reflect them back to verify their accuracy. This can lead to powerful questions from the coach and evoke new awareness that helps the client recognize the sources of their rejection.

CBT

I still have questions about the difference between RSD and some of the social anxiety and lack of sense of belongingness seen in adult ADHD, versus a separate construct of RSD. RSD was originally considered in cases of depression, so, in my opinion, even if there are not separate protocols for ADHD plus RSD, the combination of CBT approaches for depression, ADHD, and social anxiety (with the emotional regulation interventions often drawn from DBT and ACT), the CBT for adult ADHD conceptualization can be modified to address it.

15. Can you explain the key differences between ADHD coaching and Executive Function coaching? Does the latter have the same levels of accreditation?

Executive Function (EF) coaching has become a specialty within ADHD coaching with a focus on children, teens, college students, young adults, and even adults who have executive challenges in the workplace. All well-trained ADHD coaches are trained to support clients with executive function issues. However, it is not their primary focus. Executive function improvement at school or in the workplace is not the only focus.

That said, a child who is doing poorly in school and has emotional regulation issues can work with an ADHD coach who prioritizes supporting their client with improved performance-specific EF domains. When the academic issues are significantly improved, the coach may move on to another important area of the child’s life.

It’s my understanding that most EF coaches work with children who are experiencing learning challenges in the school setting. The coach focuses on improving academic performance. In the ADDCA coaching directory listed in question one, one of the specialty categories is Learning Challenges. This is where you will find coaches who focus on supporting their clients with EF coaching.

16. How would you recommend talking to a loved one with ADHD who is resistant to trying ADHD coaching but would clearly benefit from it?

For children, adolescents, teens, and college kids: Ask them to just talk to the coach. “The coach is excited to meet you and learn more about what is important to you.” Good ADHD coaches know how to have a conversation with resistant clients.

17.“One concern that I have come across with CBT is the idea around reframing negative thoughts to a positive mindset (Reframing). Some clients/patients express concern around this concept as being inauthentic because feelings can’t be debated. Can you elaborate upon this concept and the idea of recognizing (awareness) and labeling your emotions instead of reframing them.”

This is a common misconception. The cognitive modification is not an all or nothing process but entails reconsidering one’s reaction to any situation, one’s interpretation, and options for managing it. Some “negative” thoughts (“I made a mistake”) are accurate, emotions provide information, which can be helpful and noticed and do not necessarily need to be changed in order to keep open coping options. Emotional labelling has been found to reduce amygdala firing and emotional labelling with granularity (“This is my ‘I dread homework’ anxiety”) also helps move through feelings. This is where CBT has integrated many of the DBT and ACT principles. Moreover, it is fine to “feel bad” but to not make things worse by how one responds to that emotion.

18.“Can you please elaborate on ‘accurate empathy’ and perhaps give an example or two of how you display accurate empathy with a person with ADHD?”

In a nutshell, it involves good listening and empathy skills, but summarizing back and making sure one is “getting it right” in terms of the client’s experience. The task is to try to see the world “through the eyes” of the client.

19. You mentioned 3 characteristics of ADHD pertaining to creative thinking — what were they? Thank you!”

Recent studies are revealing that individuals with ADHD think more creatively than do individuals who do not have ADHD. Three facets of creative thinking that individuals with ADHD exhibit are:

1. Divergent thinking: the ability to think of many ideas from a single starting point
2. Conceptual expansion: broadening or widening an individual perspective, context, or frame of reference of a concept, subject or object that incorporates new ideas around it.
3. Overcoming knowledge constraints: thinking beyond the typical accepted restrictions regrading an idea or thing that most people assume to be true.

The content for this article was derived from the ADDitude Expert Webinar “How CBT and ADHD Coaching Help Adults Manage Their Symptoms Naturally” by David Giwerc and J. Russell Ramsay, Ph.D., which was broadcast live on October 8, 2020.

ADHD Therapy: Next Steps

• Read: ADHD Therapy Overview: The 9 Best Treatments for Children and Adults
• Learn: 7 Essential Functions of ADHD Coaching
• Download: Everything You Need To Know About CBT

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