CBT for ADHD in Youth: Back-to-School Strategies for Therapists, Teachers, and Caregivers

By Betsy Feinberg, PsyD

Beck Institute Adjunct Faculty

With back-to-school season in full swing, caregivers, teachers, and children alike are facing a familiar crossroads. Amid the difficult choices currently at play regarding COVID-19 and vaccinations, many must also return to the more typical issues that arise at school each year. For children and youth with ADHD, the start of the school year presents additional challenges.

CBT for ADHD involves evidence-based, practical applications, tips, and tools that have been shown to be effective in clinical practice. It is important to take a multi-modal approach that engages both the child as well as their caregiver(s) and teachers. For caregivers and teachers, the approach involves not only administering behavioral interventions, but also using CBT to help restructure their own thoughts about the child and reframe expectations. In many cases, effectively collaborating with the teacher is a missing piece that can help change both the child with ADHD’s mental framework and the teacher’s way of viewing their struggles.

For the therapist:

Evidence shows the most lasting and effective behavioral changes occur when we are rewarding behaviors we want to see, as opposed to punishing those we do not. Therapists often struggle with how to maintain the focus of youth with ADHD within the context of the therapy session. There are a number of strategies that can be employed, including the “mystery timer,” which is based on the concept of variable reinforcement. The therapist sets a timer for a mystery amount of time, and for every time the timer buzzes, the child gets a point for positive behaviors (e.g., being seated in their chair, focusing on the conversation, etc.). The therapist and child collaborate beforehand, discussing which behaviors are favorable, deciding on how many points earn a reward, and defining what the reward will be (this can be pre-arranged with the caregiver). Strategies like these tend to help change the dynamic in session from frustration to excitement.

For the teacher:

A practical strategy that can be used to bridge the gap between home and school is creating a home and school report card. This is a way to give kids consistent, systematic, ongoing feedback, as well as an opportunity for praise and recognition of behaviors that the teacher wants to encourage and develop, which strengthens the positive behaviors. This also allows for more seamless communication with caregivers on a regular basis regarding the functioning of the child. Like the mystery timer, the behaviors being observed should be defined well in advance, and caregivers are encouraged follow through on positive feedback with some kind of incentive or reward. In general, patients are more successful when there is regular communication between home and school and when there’s a focus on praise.

For the caregiver:

One of the most important pieces of the ADHD puzzle involves cognitive reframing on the caregivers’ part. In short, kids are not giving their caregivers a hard time – these kids are having a hard time themselves. It is easy for the caregiver to get stuck labeling children as disobedient or frustrating, which can trigger negative emotions, leading to unhelpful behaviors and interactions. When caregivers reframe the view that the child is not intentionally trying to engage in negative behaviors, their emotions tend to change to empathy. Empathetic actions impact the child, making them more motivated to work toward positive behaviors. With ADHD, the onus is on the caregiver to take some degree of leadership for behavioral interventions. When employing CBT strategies for youth with ADHD, there is an expectation to keep up with interventions in order to maintain progress. It is essential, then, for caregivers to be involved in sessions to some degree.

Since youth with ADHD are often scolded, yelled at, or misunderstood, it is likely that they will develop distortions in the way they see themselves. Over time, they may internalize these messages and start to believe they there is something inherently wrong with them that cannot be fixed. Through the course of CBT treatment, there is an opportunity to provide solid psychoeducation as to what ADHD is, to normalize the child’s experience, and to explore it together. This can help kids feel more hopeful about themselves and their future, increasing positive feelings and decreasing self-blame and self-criticism.

A final, more fun activity to do with youth struggling with ADHD is to take time to look up people with ADHD who are famous or admired by the child. This helps them see that just because they have this diagnosis, it does not mean they will not be able to have success, realize their goals, and live in accordance with their values.