ADHD Protocol (CBT)

This protocol for ADHD can be implemented both online and in a blended format, and it is based on existing protocols, scientific sources, and mental healthcare standards, adapted in a way that makes it suitable for use with NiceDay. Within this treatment, the emphasis is placed on personal strengths, building trust, and encouraging an active work attitude and autonomy. This is achieved through encouragement and motivation, shared decision-making, and involving significant others. Depending on your client's personal situation and symptoms, you can utilize supportive articles, and you can find inspiration for these at the end of the protocol.

This protocol provides therapists with guidance on how to conduct treatment within NiceDay. It is structured around various core interventions and does not need to be followed rigidly. It offers the flexibility to tailor the treatment to your client's specific situation and symptoms.
 

Core interventions

The Cognitive Behavioural Therapy (CBT) treatment for ADHD consists of the following core interventions:

📖 Psychoeducation

🧠 Sensory reduction (& complaint reduction)

📋 Thought records and skill training

🔁 Relapse prevention

💡Other interventions for ADHD treatment

• Exercise can have a mild positive effect.
• Creative therapy can enhance self-management.
• Pharmacological therapy (medication) can be used as a supplement to CBT treatment in consultation with a psychiatrist.
• Interventions aimed at improving sleep quality and nutrition can be important additions to the treatment.

The sequence
The treatment begins with psycho-education about ADHD and CBT. Next, you start with the sensory reduction component. After that, you can work on creating Thought Records and developing a step-by-step plan for new behaviours in areas relevant to your client. The treatment concludes with relapse prevention.

Pace and frequency
Depending on the severity of the symptoms and the effectiveness of the therapy, you can expect the duration to be approximately 12 to 20 sessions. It is advisable to schedule frequent sessions at the beginning of the treatment. It is important, as part of expectation management, to make agreements with your client about the duration of the treatment.
 

Outcome Feedback (OMQ and SMQ)
To monitor progress effectively, you can use two short (5-question) questionnaires that are administered around each session. Prior to each session, the Outcome Measurement Questionnaire (OMQ) assesses the severity of the symptoms. After each session, the Session Measurement Questionnaire (SMQ) evaluates the quality of the treatment session and the working relationship. You can find the manual here. If necessary, discuss the results with your client.

Flexible Time
Flexible time refers to the time you spend with your client outside of the sessions (e.g., chatting, sending psychoeducation, or writing session notes). This allows you to stay engaged with your client and monitor progress effectively. You can assess how much time is needed per client. If you need more inspiration for what you can do, refer to this article.
 

Involving Social network
Discuss with your client whether and how their social network can be involved in the treatment process. The client's environment can both facilitate and unintentionally hinder the treatment process by maintaining avoidance and safety behaviours. You can find information on how to involve the social network in the treatment process here.

🧩 Comorbidity

ADHD often coexists with other disorders. The most common comorbidities with ADHD include:

1. Anxiety disorders, such as Generalized Anxiety Disorder (GAD), panic disorder, and social anxiety. 
2. Mood disorders and mood swings.
3. Sleep disorders, including difficulties with falling asleep, staying asleep, nightmares, and sleepwalking.
4. Learning disorders such as dyslexia and dyscalculia.
5. Substance abuse.
6. Oppositional Defiant Disorder (ODD), characterized by frequent anger, conflicts, and defiant behaviour. This is a diagnosis often made in childhood.

It's important to note that not everyone with ADHD will have comorbid conditions.

💊 Medication 

Medication is often used as a complement to the treatment of ADHD, especially when the treatment is ineffective or partially effective. In some cases, symptoms are so debilitating that medication is initiated immediately alongside treatment. The goal of medication is to improve attention and concentration. Commonly prescribed medications include stimulants like methylphenidate (Ritalin, Focalin, Methylin, Concerta) and amphetamines (Adderall, Dexedrine, DextroStat).

📖 Core Intervention Psychoeducation
 

The goal of psycho-education is to provide your client with an understanding of ADHD and sensory overload while collaboratively identifying the most significant obstacles. Additionally, you begin with symptom tracking in preparation for the next core intervention, Sensory Reduction. The core intervention typically spans an average of 2 sessions.

Deepening core intervention: Psycho-education

Session (1 or 2 sessions): 35 min

What can you do?

• Explain the outcome feedback questionnaires (OMQ and SMQ).
• Discuss the psycho-education and check if there are any questions. 
• Discuss with your client the goal of the treatment.
• Explore the possibility of involving the social network in the treatment.
• Collaboratively set SMART treatment goals and establish crisis agreements if necessary.
• Discuss with your client the core symptoms of ADHD using the ADHD model and confirm their understanding of the model.

💡 Use a virtual whiteboard and share your screen during the session.

• In preparation for the next core intervention, Sensory Reduction, ask your client to keep track of moments of sensory overload. In NiceDay, activate the "Overstimulated" tracker and explain the purpose of tracking this in the coming period.
  • Trackers such as Attention Deficit, Hyperactivity, and Impulsivity can also be used based on your client's specific complaints and needs.
• Examples of exercises and assignments to do at home:
  • Encourage your client to read the provided psycho-education if they haven't already.
  • Ask your client to write down examples in their diary that align with the core symptoms of ADHD and rate them on a scale of 1-10 based on how much these symptoms impact their daily life.
  • Request that your client draw the ADHD model themselves and explain it to someone close to them.
• Share information and tips for the social network of someone with ADHD with significant others.
• Ask your client to come up with three ADHD symptoms that don't belong to the core symptoms but may still be associated with ADHD.
  
   

Session 2: 35 min

What can you do?

• Homework Discussion: Together, identify all the relevant ADHD symptoms and discuss the consequences or difficulties they may cause. You can even create a summary or draw it on a digital whiteboard.
• Discuss other peculiarities that your client associates with ADHD. This might include issues like sleep problems, missing internal cues, hyperfocus, impulsivity, addiction, or a negative self-image.
• Explain that ADHD also has many positive traits and take a moment to consider situations where these traits are noticeable. You can also share the article about "The Strengths of People with ADHD" - if applicable.
• Examples of exercises and assignments to do at home:
  • Ask your client to write down examples of additional symptoms in their diary.
  • Continue tracking sensory overload.
     

🧠 Core intervention Sensory reduction

Sensory reduction aims to help better manage sensory overload. You assess the degree of sensory overload through symptom tracking and work together to come up with practical solutions to prevent or reduce sensory overload. On average, this intervention typically requires at least 3-5 sessions.

Deepening core intervention: Sensory reduction

Session 1: 35 min

• Homework discussion: Together, check if the overview of ADHD symptoms and additional symptoms is complete. Supplement it with any additional information from the completed homework as needed.
• Explain the purpose of Sensory Reduction.
• Then, move on to recognizing sensory overload and creating an overview of stimuli. Discuss the five domains:
  •  Sensory overload can manifest in:
    • Thoughts: For example, difficulty making decisions or having distracting thoughts.
    • Emotions: Such as irritability, frustration, or responding emotionally involuntarily.
    • Behaviour: Including procrastination, canceling appointments, or hyperactivity.
    • Physical sensations: Like restlessness, inability to sit still, or headaches.
    • Consequences of behaviour: Such as negative comments from the environment.
• Create an overview of stimuli by coming up with at least five signs of sensory overload, distributed across at least three of the five domains. Also, think of signals within each chosen domain that indicate the client is not experiencing sensory overload. Place the signals on a scale of none/none - mild - moderate - significant - strong. Create the overview digitally for convenience.
  • Tip: Use the "Overstimulated" tracker for signals, check the the core intervention for an example of an overview.
• Examples of exercises and assignments for home:
  • Ask the client to assess the degree of sensory overload at least three times a day using the Overstimulated tracker. Based on these records, have the client write down three additional signs of sensory overload.

• Optionally, encourage your client to seek feedback from their environment regarding signals of sensory overload that others notice.

• Request that your client come up with three examples of how to reduce sensory overload themselves.

Session 2 : 35 min

• Homework discussion: Ask if the client has been able to use the sensory overload tracker daily and come up with three additional signs of sensory overload. Adjust the overview of stimuli as necessary.
• Discuss how to reduce stimuli and sensory overload.
• Ensure a low baseline level of stimuli, for example, by reducing auditory and visual stimuli in the environment.
• Discuss how significant others can recognize sensory overload in your client.
• Talk about how to reduce stimuli around activities (e.g., a day of rest after a day filled with stimuli).
• Discuss relaxing activities that your client can use to unwind.
• Supplement the overview of stimuli with helpful behaviours. Arrange these interventions in order of severity and necessity and link the helpful behaviour to the degree of sensory overload.
  • Generating helpful behaviours: Come up with at least 5 appropriate interventions to reduce sensory overload.
  • Discuss at least 3 interventions to prevent sensory overload as much as possible.
• Exercises and assignments for home:
  • Ask your client to daily assess the degree of sensory overload using the tracker and apply appropriate interventions from the overview.
  • Request that your client create a session note for this session.
  • Have your client come up with three additional interventions for dealing with sensory overload.
  • Encourage your client to engage in a conversation with a significant other about reducing stimuli in communication.

📋 Thought records & Skills Training
 

The goal of Thought records and Skill Training is to examine thoughts that sustain unhelpful behaviour. You identify unhelpful behaviour and unhelpful thoughts to then create a practical step-by-step plan to develop or expand skills. Depending on the number of domains you address, this typically takes at least 3 sessions.

Deepening core intervention: Thought records & Skill training

Sessions 1/2:

• Discuss Homework: Check if the overview of stimuli has been adequately filled out and discuss the applied interventions.
• Discuss and explore with the client in which domains there are problems or desires for change. You can use information from previous sessions or ask about recurring issues or comments from others. 
  Consider:
  • Self-assessment in memory, accuracy, control, task execution, and planning.
  • Time estimation and task estimation. 
  • Cleaning up, organizing, and ordering.
  • Impulsivity.
  • Frustration tolerance.
  • Self-esteem.
• Discuss the importance of Skill Training and which factors contribute or don't contribute to its success. Explain that you will work together to develop a step-by-step plan and how the relationship between thoughts and behaviour is relevant to this process.
• Next, you can collaboratively explore which unhelpful thoughts are relevant to your client, and together, you can fill out step 1 of the Thought record.
• Examples of exercises and assignments for home:
  • Ask your client to fill out step 1 of the Thought record when they encounter a problem or notice an unhelpful thought. Tip: Set a task with notification in NiceDay.
  • Request that your client create a session note for this session.
  • Have your client reflect on unfulfilled intentions. Write down all the unhelpful thoughts that played a role.
     

Session 2: 35 min

• Discuss homework: Evaluate step 1 of the Thought record together with the client. Check if it was possible to come up with unhelpful thoughts related to previous intentions.
• Based on the filled-out Thought records and the client's complaints, have the client think of concrete behaviour they would like to change.
• Discuss the benefits and drawbacks of the old behaviour.
• Introduce the step-by-step plan for new behaviour and show an example of a completed plan.
• Create a concrete step-by-step plan for the new behaviour together. Make specific arrangements for the upcoming week.
  • Old behaviour
  • Motivation for old behaviour
  • Unhelpful thought about old behaviour
  • New behaviour
  • Motivation for new behaviour
  • Alternatives for the benefits of old behaviour
  • Steps needed for the new skill.
  • Create a concrete plan
  • Helpful thoughts for challenging moments. 

💡 You can use steps 2 and 3 of the Thought record in NiceDay to practice formulating a helpful thought.

• Examples of exercises and assignments for home:
  • Ask your client to perform the agreed-upon skill training. Request feedback from your client on how it went and what the effect was.

💡 You can schedule this as a To-Do in NiceDay.

• Ask your client to fill out and execute a step-by-step plan themselves.
• Request that your client add the new behaviour to the overview of stimuli.
• Ask your client to write down the pros and cons of their old behaviour.

Session 3 to the last session: 35 min

• Discuss homework: Evaluate with the client whether the step-by-step plan was successful. Modify the plan if necessary. Continue with the step-by-step plan until it succeeds.
• If necessary, choose a different skill to work on with your client. Create a step-by-step plan for new behaviour together. You can repeat these steps until you are both satisfied.
• Examples of exercises and assignments for home:
  • Ask your client to execute the step-by-step plan. Request feedback from your client on how it went and what the effect was.

💡 You can schedule this as a To-Do in NiceDay.

• Ask your client to fill out and execute a step-by-step plan themselves.
• Request that your client add the new behaviour to the overview of stimuli.
   
   

🔁 Core intervention Relapse prevention

The goal of Relapse Prevention is to identify how someone can recognize and monitor potential relapse, what their pitfalls are, and what strategies they can apply to cope with symptoms or situations. This typically takes about 1-2 sessions.

Deepening core intervention Relapse prevention
 

Session (1 or 2 sessions) 35 min

• Reflect on the progress of the OMQ and SMQ and discuss any other (ROM) questionnaires.
• Evaluate the treatment:
  • Discuss the effect of the treatment.
  • Identify which obstacles have been overcome and which ones are still present.
  • Predict and normalize: It is normal to encounter obstacles in the future. Stress, fatigue, and/or life changes can play a role in this.
• Together, create the relapse prevention plan:
  • Make a list of situations and issues where a relapse into "old behaviour" is a risk.
  • Have your client write down a strategy for each situation that can be applied in those specific circumstances.
• Exercises and assignments for home:
  • Encourage your client to continue applying everything they have learned. This includes continuing to use the app, such as filling out trackers to stay alert to overstimulation and using the Thought record to identify unhelpful thoughts.
  • Ask your client to complete the relapse prevention plan.
     

📚 Use blog articles

Depending on your client's personal situation and symptoms, you may choose to send supportive blogs. These are written by professionals and experts with personal experience and can be found on niceday.app. Examples include:

1. Everything, everywhere at once
2. How do you maintain focus?
3. How do you deal with overstimulation and emotional intensity?
4. Learn to relax
5. Why is mental relaxation so important?
6. Why do we use stimulants?
7. Am I good enough?
8. Do I have a realistic self image?
9. Minimalism: tidy house, tidy mind
10. Give yourself peace at home
11. Do you listen to your inner critic?

Sources

• Vink, S. (2021). Cognitieve gedragstherapie bij volwassenen met ADHD. Handleiding voor therapeuten. BSL.
• Vink, S (2021). Los van de chaos. Werkboek voor cliënten. BSL.
• https://www.ggzstandaarden.nl/zorgstandaarden/adhd/