Incautiously Optimistic: Positively Valenced Cognitive Avoidance in Adult ADHD

Abstract

Clinicians who conduct cognitive-behavioral therapy (CBT) targeting attention-deficit/hyperactivity disorder (ADHD) in adulthood have noted that their patients sometimes verbalize overly positive automatic thoughts and set overly optimistic goals. These cognitions are frequently related to failure to engage in compensatory behavioral strategies emphasized in CBT. In this paper, we offer a functional analysis of this problematic pattern, positively-valenced cognitive avoidance, and suggest methods for addressing it within CBT for adult ADHD. We propose that maladaptive positive cognitions function to relieve aversive emotions in the short-term and are therefore negatively reinforced but that, in the long-term, they are associated with decreased likelihood of active coping and increased patterns of behavioral avoidance. Drawing on techniques from Behavioral Activation (BA), we offer a case example to illustrate these concepts and describe step-by-step methods for clinicians to help patients recognize avoidant patterns and engage in more active coping.

Development and Evaluation of the ADHD Cognitions Scale for Adults

“…Consistent with the cognitive-behavioral model of ADHD, we expected that ACS scores would be positively associated with ADHD symptoms and functional impairment. Furthermore, consistent with the view that ADHD-related cognitions may function to avoid negative affect (Knouse & Mitchell, 2015), we also predicted that scores on the ACS would be positively associated with disengagement coping strategies (cognitive and behavioral avoidance, self-distraction, denial) and negatively associated with engagement coping (active coping, positive reframing, acceptance, planning).…”

“…Similarly, Knouse and Mitchell (2015) have proposed that “overly positive” thoughts associated with ADHD often constitute avoidance behavior—that is, the act of thinking these thoughts may be reinforced by escape from negative affect that is triggered when clients are reminded of the need to engage in non-preferred tasks or similar anxiety-provoking situations. For example, a thought such as, “I’ll just do this one thing first,” gives the client permission to avoid a task that may begin to evoke negative affect and the act of thinking the permission-giving thought is subsequently reinforced by the temporary removal of negative affect.…”

“…The ACS may also be useful to clinicians conducting CBT with adults with the disorder. For example, the measure could be used to identify problematic thoughts associated with failure to use self-regulation skills and awareness of these thoughts could then serve as a cue for use of specific skills (see Knouse & Mitchell, 2015 for a detailed description). Completing the measure and discussing it may also help clients to identify their own idiosyncratic “permission-giving thoughts” that tend to precede problematic avoidance.…”

“…However, there is growing recognition that maladaptive patterns of thinking are not restricted to these “negative” thinking styles in adult ADHD (Knouse & Mitchell, 2015). On the contrary, recurrent problematic thoughts in adults with ADHD may appear quite optimistic on the surface—for example, “I’m the kind of person who does my best work at the last minute.” Such cognitions are topographically different from typical depressive and anxious cognitions targeted in most manualized CBT approaches for adults diagnosed with ADHD, but are functionally thought to have a similar outcome: failure to engage in self-management strategies.…”

Mindfulness Meditation Training for Attention-Deficit/Hyperactivity Disorder in Adulthood: Current Empirical Support, Treatment Overview, and Future Directions

“…Adult ADHD CBT treatments include cognitive therapy modules primarily based on traditional cognitive therapy techniques that emphasize changing the content of negative thinking (see Knouse & Mitchell, in press, for an exception). Mindfulness, however, focuses less on changing the content of thinking and places greater emphasis on observing cognitions and changing one’s relationship with those cognitions.…”