Strategies to enhance engagement in CBT for adult ADHD: an innovation tournament with stakeholders

Objective Adults with ADHD report challenges engaging in cognitive-behavioral therapy (CBT). This study investigates practices that might be applied to improve intervention fit and therapeutic engagement of CBT for adults with ADHD. Method We conducted an Innovation Tournament (IT) and member checking with participants ( N= 102) who were adults with ADHD and mental health practitioners who regularly treat adults with ADHD. Go-Zone plots were utilized to identify strategies with the highest feasibility and importance as well as strategies with low feasibility and/or importance that might be candidates for de-implementation. Barriers to CBT engagement and practitioner implementation of practices were also evaluated qualitatively. Results A range of engagement barriers were identified, chief among them practitioner low understanding of ADHD (44.4%) and lack of attention to relevant impairments (33.3%). The highest rated focal areas for CBT were task management, organization, planning, and prioritization, emotion regulation strategies, responding to negative/maladaptive thoughts, anti-procrastination and self-motivation strategies, and long-term goal setting. Top recommendations for engagement strategies include ensuring high therapist knowledge of ADHD and 17 elements consistent with Motivational Interviewing. Some practices commonly found in CBTs for ADHD were rated as unpopular with stakeholders, most notably providing weekly ratings of ADHD symptoms as progress monitoring. Some practices rated as important to adults with ADHD were rated as not feasible to practitioners—most notably reducing shame and nurturing confidence. Implementation barriers identified were primarily related to low practitioner knowledge and skills, but also sometimes systemic constraints on practice. Conclusions Implementation of recommended practices noted in this study should be tested empirically to understand the extent to which they increase engagement and effectiveness over standard practice.